History

Fact Explanation
Vulval soreness Vulvovaginal candidiasis is a lower genital tract infection caused by the fungus of the genus Candida, which is a commensal of the gastrointestinal and genital tract. Candida albicans accounts for about 80-92% of the cases.[1] Predisposing factors for the infection are pregnancy, immuno-suppression, diabetes mellitus, broad spectrum antibiotics, vaginal douching etc.
Pruritus vulvae Due to inflammation of the vulva and the irritant effect of the vaginal discharge.[2]
Thick curd like vaginal discharge Candidiasis produces a characteristic per-vaginal discharge which consists of thick white colored plaques commonly referred to as 'cottage cheese' & is usually non-offensive.[2]
Superficial dyspareunia Dyspareunia is pain during sexual intercourse and is felt superficially in vulvovaginal candidiasis due to the inflammation of the external genitalia.[2]
Dysuria Inflammation of the external genitalia can lead to involvement of the lower urethra and hence urinary symptoms.[2]
Presentation with recurrent episodes of infection Recurrent infection is defined as at least four episodes of infection per year. Recurrent infection is rare. Of women aged over 25, greater than 50% develop vulvovaginal candidaisis and of these only about 5% develop recurrent disease.[3] Inadequate treatment, continued presence of a predisposing factor & resistant strains of the organism can lead to recurrent infections. Rarely non-albican species can also cause vulvovaginal candidiasis where the disease tends to be more severe and recurrent.[4] [5]
References
  1. National Guideline on the Management of Vulvovaginal Candidiasis. British Association for Sexual Health & HIV. 1999 Aug [viewed 7th April 2014]. Available from: www.bashh.org/documents/50/50.pdf‎
  2. ECKERT LO, HAWES SE, STEVENS CE, KOUTSKY LA, ESCHENBACH DA, HOLMES KK. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstet Gynecol [online] 1998 Nov, 92(5):757-65 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9794664
  3. RINGDAHL E.N. Treatment of Recurrent Vulvovaginal Candidiasis. American Family Physician. 2000 Jun, 61(11), 3306-3312.
  4. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  5. HOLLAND J, YOUNG ML, LEE O, CHEN S. Vulvovaginal carriage of yeasts other than Candida albicans. Sexually transmitted infections, 2003, 79(3), 249-250.

Examination

Fact Explanation
Vulval edema & erythema Due to inflammation of the vulva.[1]
Vulval excoriations and fissures Can be aggravated due to the physical trauma due to scratching associated with pruritus vulvae.[2]
Speculum examination This may reveal inflammation of the vulva/vagina and the per-vaginal discharge which can be observed as white plaques on the vulva & vaginal wall.[3] [4] The appearance of the cervix is usually normal.
References
  1. CKERT LO, HAWES SE, STEVENS CE, KOUTSKY LA, ESCHENBACH DA, HOLMES KK. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstetrics & Gynecology, 1998 Nov, 92, 757-765.
  2. 2011 European (IUSTI/WHO) Guideline on the Management of Vaginal Discharge. International Union against Sexually Transmitted Infections. 2011 [ Viewed on 09 April 2014]. Available from : http://www.iusti.org/regions/europe/pdf/2011/Euro_Guidelines_Vaginal_Discharge_2011.Intl_Jrev.pdf
  3. National Guideline on the Management of Vulvovaginal Candidiasis. British Association for Sexual Health & HIV. 1999 Aug [viewed 7th April 2014]. Available from: www.bashh.org/documents/50/50.pdf‎
  4. ECKERT LO, HAWES SE, STEVENS CE, KOUTSKY LA, ESCHENBACH DA, HOLMES KK. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstet Gynecol [online] 1998 Nov, 92(5):757-65 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9794664

Differential Diagnoses

Fact Explanation
Contact dermatitis Contact dermatitis of the vulva is a skin condition that is caused by exposure to irritants such as fabric softeners, body soaps, deodorized tampons etc.[1] This non-infective condition presents with vulvar itching and burning. Swabs of the affected area help diagnose this condition by excluding signs of infection.
Allergic reactions Various allergens can cause a reaction in the delicate skin of the external genitalia leading to a clinical picture similar to contact dermatitis of the vulva.[2]
Trichomoniasis This a lower genital tract infection that is caused by the protozoa Trichomonas vaginalis. It is a sexually transmitted infection that can lead to severe vulvovaginitis. Presentation is vulval pain, itching and a characteristic vaginal discharge which is foul smelling,frothy and yellowish green in color. Diagnosis is by visualization of the organism under the microscope on a wet mount. [3]
Bacterial vaginosis A condition that occurs due to colonization of the lower genital tract by anaerobic organisms with reduction in the naturally occurring lactobacilli. Presentation is with malodorous greyish-white vaginal discharge which is adherent to the vaginal wall. There is minimal inflammation of the vulva & vagina.[4]
References
  1. FISCHER Gayle. Treatment of vaginitis and vulvitis. Australian prescriber, 2001 March, 24, 59-61.
  2. NARDELLI A, DEGREEF H, GOOSSENS A. Contact allergic reactions of the vulva: a 14-year review. Dermatitis [online] 2004 Sep, 15(3):131-6 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15724347
  3. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  4. SOBEL JD. Bacterial vaginosis. Annu Rev Med [online] 2000:349-56 [viewed 12 September 2014] Available from: doi:10.1146/annurev.med.51.1.349

Investigations - for Diagnosis

Fact Explanation
The diagnosis of this infection should be based on clinical findings confirmed by laboratory investigations. The clinical symptoms and signs alone are not specific for the diagnosis.[1] Investigations can help exclude the conditions that present in a similar manner.
Microscopy Specimens are collected by a perineal swab and/or vaginal swab. The vaginal discharge is examined for spores & pseudohyphae under the microscope. This can be done under gram stain( sensitivity 65-68%), wet film examination(Sensitivity 40-60%) & KOH solution(Sensitivity 70%).[1]
pH of vaginal fluid A normal vaginal pH (4.0-4.5) can be observed. A vaginal pH of more than 5 is suggestive of bacterial vaginosis/ trichomoniasis.[2]
Fungal culture Direct plating of specimens on to Sabouraud’s media should be considered in all symptomatic cases where microscopy is inconclusive or identification of the species is needed.[3]
Further testing to type the species This is required in resistant cases or very severe cases for correct selection of the appropriate anti-fungal agent according to the species. PCR can be used for this purpose. Some patients may carry more than one species type.[4]
References
  1. National Guideline on the Management of Vulvovaginal Candidiasis. British Association for Sexual Health & HIV. 1999 Aug [viewed 7th April 2014]. Available from: www.bashh.org/documents/50/50.pdf
  2. WHITE DJ, VANTHUYNE A. Vulvovaginal candidiasis Sex Transm Infect [online] 2006 Dec, 82(Suppl 4):iv28-iv30 [viewed 12 September 2014] Available from: doi:10.1136/sti.2006.023168
  3. 2011 European (IUSTI/WHO) Guideline on the Management of Vaginal Discharge. International Union against Sexually Transmitted Infections. 2011 [ Viewed on 09 April 2014]. Available from : http://www.iusti.org/regions/europe/pdf/2011/Euro_Guidelines_Vaginal_Discharge_2011.Intl_Jrev.pdf
  4. MAHMOUDI RAD M, ZAFARGHANDI ASH, AMEL ZABIHI M, TAVALLAEE M, MIRDAMADI Y. Identification of Candida species associated with vulvovaginal candidiasis by multiplex PCR. Infect Dis Obstet Gynecol [online] 2012:872169 [viewed 12 September 2014] Available from: doi:10.1155/2012/872169

Investigations - Screening/Staging

Fact Explanation
Screening for diabetes mellitus For exclusion of diabetes as a predisposing factor in recurrent infection.[1][2]
References
  1. RINGDAHL E.N. Treatment of Recurrent Vulvovaginal Candidiasis. American Family Physician. 2000 Jun, 61(11), 3306-3312.
  2. 2011 European (IUSTI/WHO) Guideline on the Management of Vaginal Discharge. International Union against Sexually Transmitted Infections. 2011 [ Viewed on 09 April 2014]. Available from : http://www.iusti.org/regions/europe/pdf/2011/Euro_Guidelines_Vaginal_Discharge_2011.Intl_Jrev.pdf

Management - General Measures

Fact Explanation
Avoid tight fitting synthetic underwear and advise on use of cotton underwear. For relief of vulval soreness, discomfort, itching etc.[1]
Avoid local irritants (e.g. perfumed products, soaps, vaginal douching). To avoid aggravating the local inflammatory process.[1]
Modification of risk factors If the patient is on high-dose combined oral contraceptive pill change to low dose pills can be considered. If persistent or recurrent infection occurs in spite of change, change to progesterone-only pill can be considered.Long acting injectable progestogen products (Depo-Provera) can also be used as an alternative.[2] If the patient is diagnosed with diabetes mellitus good glycemic control should be maintained. Avoid repeated courses of broad spectrum antibiotics.
Educate and counsel the patient The patient should be provided information about the disease.[3] Reassurance can be provided by educating that candidiasis is not a sexually transmitted infection.
References
  1. National Guideline on the Management of Vulvovaginal Candidiasis. British Association for Sexual Health & HIV. 1999 Aug [viewed 11th April 2014]. Available from: www.bashh.org/documents/50/50.pdf‎
  2. DENNERSTEIN GJ. Depo-Provera in the treatment of recurrent vulvovaginal candidiasis. Journal of Reproductive Medicine, 1986 September, 31(9), 801-803.
  3. 2011 European (IUSTI/WHO) Guideline on the Management of Vaginal Discharge. International Union against Sexually Transmitted Infections. 2011 [ Viewed on 09 April 2014]. Available from : http://www.iusti.org/regions/europe/pdf/2011/Euro_Guidelines_Vaginal_Discharge_2011.Intl_Jrev.pdf

Management - Specific Treatments

Fact Explanation
Anti-fungal therapy Azoles/ imidazoles are the mainstay of treatment. Other anti-fungals such as nystatin are also used. Routes of administration include local topical application (creams & pessaries) and oral therapy depending on the circumstances. Pessary treatment can be with a single pessary or a course of multiple low dose pessaries. The cure rate of imidazoles is 80-95% while nystatin has a cure rate of 70-90%.[1]
Treatment of uncomplicated infection The commonly used topical anti-fungal agents include clotrimazole, econazole, miconazole and nystatin. Commonly used regimes - single 500mg clotrimazole pessary or 100mg clotrimazole pessaries over 6 days, clotrimazole 5% vaginal cream 5g stat, single 150mg econazole pessary, nystatin pessary(100000 units) 2 weeks etc. Oral imidazoles can also be used in the management of uncomplicated infections. Commonly used regimes include fluconazole 150mg single dose & itraconazole 200mg twice a day for one day.[2]
Treatment of complicated infection An extended duration of therapy is needed. A two week course of the topical anti-fungals can be used.[2]
Management of recurrent infection An induction regimen followed by maintenance therapy is used to manage recurrent infection. Each patient's management plan needs to be individualized according to the patient's presentation since no optimal treatment has being defined.[3] Regimes Popular regimes - Fluconazole 100mg weekly for 6 months, Itraconazole 400mg monthly for 6 months, Clotrimazole pessary 500mg weekly for 6 months etc. There is a 90% cure rate at six months of therapy.[4] Abrupt cessation of therapy may lead to relapse.[5]
Vulvovaginal candidiasis in pregnancy These patients are treated with topical azoles which have shown no adverse effects to both the mother and fetus. Longer courses may be needed. However oral therapy is contraindicated.[6]
Management of asymptomatic carriers. Up to 30-40% of women may harbour Candida albicans without symptoms.[7] These women do not require treatment. Asymptomatic carriers detected during pregnancy also do not require treatment.
Sexual partners Treating the asymptomatic male partner is not recommended. Treatment can be considered if the female partner is developing recurrent infections.[8]
References
  1. National Guideline on the Management of Vulvovaginal Candidiasis. British Association for Sexual Health & HIV. 1999 Aug [viewed 7th April 2014]. Available from: www.bashh.org/documents/50/50.pdf‎
  2. REEF SE et al. Treatment options for vulvovaginal candidiasis. Clinical Infectious Disease, 1995, 20(Suppl.1), S80-S90.
  3. RINGDAHL E.N. Treatment of Recurrent Vulvovaginal Candidiasis. American Family Physician. 2000 Jun, 61(11), 3306-3312.
  4. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  5. FISCHER Gayle. Treatment of vaginitis and vulvitis. Australian prescriber, 2001 March, 24, 59-61.
  6. YOUNG GL, JEWELL D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database Syst Rev [online] 2001:CD000225 [viewed 12 September 2014] Available from: doi:10.1002/14651858.CD000225
  7. CARR PL, FELSENSTEIN D, FRIEDMAN RH. Evaluation and Management of Vaginitis J Gen Intern Med [online] 1998 May, 13(5):335-346 [viewed 12 September 2014] Available from: doi:10.1046/j.1525-1497.1998.00101.x
  8. BiSSCHOP MP, MERKUS JM, SCHEYGROND H, VAN CUTSEN J. Co-treatment of the male partner in vaginal candidosis: a double blind randomized control study. British Journal of Obstetrics & Gynecology, 1986, 93, 79-81.