Candida vulvovaginitis

Background

Labeled vulva, showing external and internal views.

Pelvic anatomy including organs of the female reproductive system.

• Local fungal infection caused by the Candida genus (most commonly Candida albicans)
• Most commonly seen in females in high estrogen states: pregnancy, oral contraceptive use, obesity, diabetes mellitus
• Not considered an STI although it can be transmitted by sexual intercourse
• May occur in premarnarcheal girls (rare)
• Can occur as a result of antibiotic use

Types

• Uncomplicated (must have all)
  • Sporadic infection
  • Mild-moderate symptoms
  • Due to Candida albicans (suspected or proven)
  • Immunocompetent
• Complicated (presence of ANY of the following)
  • Any species other than C. albicans
  • Recurrent infection (defined as ≥4 episodes per year)
  • Severe symptoms or findings
  • Poorly controlled diabetes, immunocompromising conditions (such as HIV), debilitation, or immunosuppressive therapy (e.g., corticosteroids)

Clinical Features

Candida vaginitis

• Vulvar pruritus - most common and specific symptom
• Vaginal discharge - varies from little to copious and from watery to cottage-cheese like
• Malodorous smell is unusual (if present favors diagnosis of Bacterial vaginosis)
• Intense vulvovaginal pruritus or burning
• Dyspareunia
• Dysuria

Differential Diagnosis

Vulvovaginitis

• Bacterial vaginosis
• Candida vaginitis
• Trichomonas vaginalis
• Contact vulvovaginitis
  • Bubble baths and soaps
  • Deodorants, powders, and douches
  • Clothing
• Atrophic vaginitis due to lack of estrogen (AKA Vulvovaginal atrophy)
• Lichen sclerosus
• Tinea cruris
• Chlamydia/Gonorrhea infection
• Pinworms
• Vaginal foreign body
  • Toilet paper
  • Other
• Genitourinary syndrome of menopause
• Foreign body
• Allergic reaction
• Normal physiologic discharge

Evaluation

KOH test on a vaginal wet mount, showing slings of pseudohyphae of Candida albicans surrounded by round vaginal epithelial cells.

Work-up

• Urine pregnancy
• Wet mount
• Consider blood glucose (if recurrent, to check for occult DM)
• Consider tests for STIs

Diagnosis

• Cotton cheese curd-like non-odorous vaginal discharge on pelvic exam
• Vaginal pH < 4.5
• Vaginal wet mount
  • Hyphae and yeast buds
  • Candida does not cause WBCs on wet mount → if present, consider co-infection with other vaginitides or STI

Management

• Do not treat if asymptomatic
• Sexual partners should not be treated unless the patient has frequent recurrences
• Does not need a test of cure

Antifungals

Uncomplicated

There is little resistance to azole medications; treatment often dictated by patient preference.

• Fluconazole 150mg PO once (preferred)
  • A second dose at 72hrs may be given if patient is still symptomatic
• Intravaginal therapy
  • Clotrimazole 1 % cream applied vaginally for 7 days OR
  • Clotrimazole 2% applied vaginally for 3 days
  • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
  • Butoconazole 2% applied vaginally x 3 days
  • Tioconazole 6.5% applied vaginally x 1

Complicated

Severe or immunosuppressed

• Fluconazole 150mg PO q72h x 3 doses

Non-albicans species

• For example, C. glabrata, C. krusei and other atypical Candida spp.
• Boric acid vaginal suppository intravaginal qday x ≥14 days
  • Can be fatal if taken orally
• If empirically treated and later is found to have non-albicans Candida spp., no change in therapy is needed if patient is improving (otherwise switch to boric acid.

Recurrent (≥ 4 infections in a year)

• Treat as for uncomplicated (see above)
• Once therapy completed, prescribe long-term treatment
  • Fluconazole 150mg PO qweek x 6 months, OR
  • Intravaginal medication, such as clotrimazole 500mg PV qweek or 200mg PV twice a week

Pregnant Patients

• Intravaginal clotrimazole or miconazole are the only recommended treatments
• Duration is 7 days
• PO fluconazole associated with congenital malformations and spontaneous abortions

Disposition

• Outpatient
  • Refer all "complicated" cases to gynecology

See Also

• Vulvovaginitis
• Candidiasis