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Candida Vulvovaginitis for Family and OBGYN Medicine

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This is defined as vulvovaginal inflammation due to candida species. This is the second most common cause of vaginitis and is not considered to be a sexually transmitted infection.

It’s exact prevalence isn’t exactly known to due the fact many are clinically diagnosed and many women self treat with over the counter medication.

The species candida albicans is responsible for about 90% of all infections and the remaining 10% is cause by candida glabrata. Infection is thought to occur from the migration of candida from the rectum to the vaginal canal.

It’s also important to note that candida is part of the normal vaginal flora and the exact cause or mechanism that occurs from asymptomatic colonization to the inflammatory process is poorly understood.

Risk factors include:

Diabetes, recent antibiotic use, increased estrogen levels, immunosuppression, contraceptive devices, and intercourse.

Although it’s not considered a sexually transmitted disease – it can still be transmitted sexually if the partner has infection. Douching, tampons, and tight clothing are weak risk factors.

It’s thought that those with recurrent infection (over 4 per year) have a genetic susceptibility.

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Clinical Features

Patients often present with itching, irritation, dysuria, and dyspareunia. Symptoms tend to worsen the week before menses.

Discharge may or may not be present. Classically, it presents as thick, white, adherent, and cottage cheese like. But, it can also be watery, thin, and can appear like any other form of vaginitis.

If doing a pelvic exam you will notice erythema of the vulva and vaginal canal, edema of the vulva, and excoriations.

Diagnosis

The majority of women do present classically and can be treated empirically. But, if unsure of the diagnosis or if the woman already tried trial of over the counter medication, then laboratory testing with a wetmount or culture should be done.

Keep in mind that microscopy can be negative in up to half those patients diagnosed with candidiasis via culture. The wetmount can also exclude bacterial vaginosis and trichomoniasis as a possible diagnosis or even as a co-infection.

In women who have a negative wetmount, but persistent symptoms, a culture should be ordered. The culture might also reveal non-albicans infection resistant to azoles.

Consider diabetes testing in those with recurrent or persistent disease.

Treatment

Treatment is indicated for women with symptoms only. Treatment of the partner isn’t necessary and the woman can continue having sex – if she so chooses.

The healthy woman with uncomplicated disease can be treated with oral fluconazole or with a topical azole (eg clotrimazole)- both have a 90% cure rate.

The difficulty arises in the complicated case: severe disease, pregnancy, uncontrolled DM, immunosuppression, recurrent infection, and those with non-albicans infection.

These women typically need longer dosing. Fluconazole maintains therapeutic levels in vaginal secretions for 72 hours. So, we can dose one 150mg dose every 72 hours (3 days) for 3 doses total in these women. When giving topical therapy – it’s recommended to treat for 7-14 days in this population.

Women who are pregnant should be treated first line with topical azole therapy (clotrimazole) for 7 days. Candidiasis is not associated with adverse fetal outcomes. Fluconazole has been shown to increase the risk of miscarriage especially when given in the first trimester – by as much as 50%.

Those with recurrent infection can be switched to lower dose estrogen pill, should have control of glucose, should avoid lubricants, and avoid panty liners. After curing infection as discussed (fluconazole 150mg every 72 hours for 3 doses), then suppressive therapy can be started with once weekly fluconazole dosing for 6 months. No routine laboratory monitoring is indicated when treating with fluconazole for extended periods of time.

Half these women who are treated with suppressive therapy will relapse as soon as the fluconazole is stopped.