Vulvovaginal Candidiasis
Jill C. Cash and Rhonda Arthur
Definition
A.Candidiasis (also known as moniliasis) is a common, yeast-like fungal infection of the vulva and vagina. In 90% of the cases, the cause is Candida albicans infection.
Incidence
A.Approximately 75% of all women have at least one episode of candidiasis. It is estimated that 50% of these women have recurrences. Yeast has been identified with circumcised males, but symptomatic complaints are more common with uncircumcised males.
Pathogenesis
A.Multiple fungal species cause candidiasis, including C. albicans (90%), Candida tropicalis, Torulopsis glabrata (10%), Candida parapsilosis, and Candida krusei.
B.C. albicans, C. tropicalis, or T. glabrata are part of the normal flora of the mouth, gastrointestinal (GI) tract, and vagina. They may become pathogenic with changes in the vaginal pH that encourage the overgrowth of the fungus.
C.The incubation period is 96 hours.
Predisposing Factors
A.Diabetes.
B.Systemic antibiotic use.
C.Pregnancy.
D.Oral contraceptive pill use.
E.Obesity.
F.Warm climate.
G.Immunocompromised.
H.HIV.
I.Wearing tight, restrictive clothing.
J.Corticosteroid use.
K.Tub bathing.
L.Frequent use of hot tubs or whirlpools.
Common Complaints
A.Thick white cheesy
vaginal discharge.
B.Itching, mild to intense vulvar pruritus.
C.Vaginal or vulvar irritation, red and swollen.
D.Discomfort during and after sexual intercourse.
Other Signs and Symptoms
A.Vulvar excoriation.
B.Vaginal swelling or inflammation.
C.Burning with urination.
D.Burning with or during intercourse.
E.Increased symptoms near menses.
Subjective Data
A.Determine onset, course, and duration of symptoms; note if infection is first occurrence, recurrent, persistent, or chronic.
B.Obtain medication history; include antibiotics, steroids, and birth control pills.
C.Review the patient’s past medical history, and review systems for evidence of diabetes, HIV, or any immunocompromise.
D.Review hobbies that include the use of hot tubs, whirlpools, frequent swimming, or tight exercise clothing.
E.Review the patient’s history of wearing polyester underwear, wearing underwear to bed, or wearing tight jeans.
F.Review previous treatment, self-treatment measures, and compliance with previous treatments.
G.Determine if the patient is pregnant; note first day of last menstrual period (LMP).
H.Review sexual activity and partners. Do the partner(s) have any of the same symptoms, jock itch,
or oral candidiasis?
I.Review the use of vaginal deodorants or spray, scented toilet paper, tampons, pads, and douching.
J.Has there been any change in soaps, laundry detergent, or fabric softeners?
K.Review diet for high sugar content.
Physical Examination
A.Check temperature, pulse, and blood pressure (BP).
B.Inspect:
1.Inspect the vulva for inflammation, fissures, lesions, excoriation, rashes, and condyloma.
2.Examine the hair (Hart’s) line and skin folds for inflammation, irritation, or skin breakdown.
3.Note skin changes that suggest secondary bacterial infection (erythema, drainage). Inflammation that spares the skin folds is consistent with contact irritation. Inflammation that is within the skin folds suggests Candida.
C.Palpate:
1.Perform external exam for enlarged or tender inguinal lymph nodes, vulvar masses, and lesions.
2.Back: Assess for costovertebral angle (CVA) tenderness.
D.Pelvic examination:
1.Inspect: Observe side walls of vagina. Note amount, smell, and color of the discharge. Typical discharge with Candida is adherent to vaginal side walls and characteristically thick, white, and curd-like (resembles cottage cheese). Side walls may exhibit erythema. The discharge has a musty odor.
2.Speculum examination: Inspect the cervix for discharge and friability.
3.Bimanual examination: Check for cervical motion tenderness (CMT). Palpate for the size of the uterus and for adnexal masses or tenderness.
Diagnostic Tests
A.Wet prep with 10% potassium hydroxide and normal saline prep. Yeast hyphae and/or spores are determined by microscopic examination of vaginal discharge prepared with 10% potassium hydroxide or normal saline. A positive whiff test indicates bacterial vaginosis (BV).
B.Test discharge with nitrazine paper. The pH with candidiasis remains in the normal range of less than 4.5.
C.Consider 2-hour glucose testing.
D.Consider testing for gonorrhea (GC) and Chlamydia trachomatis (CT).
E.Herpes culture, if lesions present.
F.Urinalysis and culture, if indicated.
Differential Diagnoses
A.Vulvovaginal candidiasis.
B.Vulvar dystrophy.
C.Allergic vulvitis.
D.BV.
E.Urinary tract infection (UTI).
F.CT.
G.GC.
H.Trichomonas.
I.Herpes simplex virus (HSV) type 2.
J.Chemical vaginitis.
K.Normal physiologic discharge.
Plan
A.General interventions:
1.Although vaginal candidiasis is treated using over-the-counter (OTC) products, encourage patients with initial presenting symptoms to have an evaluation to rule out other vaginal infections prior to self-treatment.
2.Consider treating partners. While candidiasis is not considered an sexually transmitted infection (STI), it can be sexually transmitted. The partner should be treated in cases of recurrent infections, even if the partner is asymptomatic.
3.For recurrent infections, consider fasting and 2-hour postprandial glucose tests for chronic yeast infections.
4.Consider testing for HIV for chronic yeast infections.
B. 
See Section III: Patient Teaching Guide Vaginal Yeast Infection
:
1.Patients should be encouraged to present for evaluation if, after appropriate therapy has been instituted, they continue to have symptoms.
2.Treatment should continue even during menstruation.
C.Pharmaceutical therapy:
1.Vaginal antifungal creams: Mild cases may respond to 3 days of therapy; severe cases may require 10 to 14 days. Some of these preparations are available in vaginal suppository form for a one- or three-night regimen with proven efficacy. Most OTC zoles
are effective:
a.Clotrimazole (Gyne-Lotrimin, Lotrimin, Mycelex, Mycelex-G): one applicator full at bedtime for 7 days.
b.Miconazole (Monistat): one applicator full at bedtime for 7 days.
c.Butoconazole nitrate (Femstat): one applicator full at bedtime for 7 days.
d.Terconazole (Terazol): one applicator full at bedtime for 7 days.
e.Terconazole vaginal antifungal cream is not available OTC. Imidazole drugs (miconazole, clotrimazole, econazole, butoconazole) are not as effective for non-C. albicans infections as are triazole compounds.
2.Oral antifungal agents:
a.Fluconazole (Diflucan) 150 mg orally once. If treatment is not successful, prescription may be refilled one time; if it is still unsuccessful, consider treating the patient’s partner and/or glucose testing for diabetes.
b.Nystatin one tablet (100,000 units) orally or vaginally for 14 days. Nystatin may be taken twice a day or at bedtime.
Follow-Up
A.The patient who presents with recurrent candidiasis should be evaluated for HIV and/or other immunocompromised etiologies and diabetes mellitus (DM).
B.If fasting and 2-hour blood glucose testing are normal, other options for recurrent candidiasis include treatment with clotrimazole one applicator every other week for 2 months. If the patient remains symptom-free, reduce treatment to once each month, in the week prior to menstrual period.
C.If recurrent candidiasis persists, request laboratory produce a yeast culture Candida for T. glabrata or C. tropicalis. Gentian violet, which disrupts the chitin cell wall, has been found to be effective as an office-based option for some patients.
Consultation/Referral
A.Consult or refer the patient to a physician if there is no response to the previous treatments and/or in presence of concurrent systemic disease.
Individual Considerations
A.Pregnancy may lead to an increase in vulvovaginal candidiasis because of the increased glycogen content of the vagina and to the stimulatory effects of estrogen and progesterone on candidal growth. OTC antifungal creams are appropriate for use in this population if there is no rupture of membranes. Candidiasis may be transmitted from the infected mother to the newborn at delivery.
B.Partners should be evaluated if the patient presents with recurrences. OTC antifungal creams are appropriate for use in this population.