Candida vulvovaginitis: Difference between revisions
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==Background== | ==Background== | ||
*Local fungal infection caused by the [[Candida]] genus | [[File:Vulva Figure 28 02 02.jpg|thumb|Labeled vulva, showing external and internal views.]] | ||
[[File:Blausen 0400 FemaleReproSystem 02b.png|thumb|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 | *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 | *Not considered an STI although it can be transmitted by sexual intercourse | ||
*May occur in premarnarcheal girls (rare) | *May occur in premarnarcheal girls (rare) | ||
*Can occur as a result of antibiotic use | |||
===Types=== | ===Types<ref>Adapted from ACOG practice bulletin</ref>=== | ||
*Uncomplicated | *Uncomplicated (must have all) | ||
**Sporadic | **Sporadic infection | ||
** | **Mild-moderate symptoms | ||
** | **Due to ''Candida albicans'' (suspected or proven) | ||
** | **Immunocompetent | ||
*Complicated | *Complicated (presence of ANY of the following) | ||
**Recurrent infection | **'''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 | ==Clinical Features== | ||
[[File:Candida vaginitis.JPG|thumb|Candida vaginitis]] | [[File:Candida vaginitis.JPG|thumb|Candida vaginitis]] | ||
*Vulvar [[pruritus]] - most common and specific symptom | *Vulvar [[pruritus]] - most common and specific symptom<ref name=candida>Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.</ref> | ||
*Vaginal discharge - varies from little to copious and from watery to cottage-cheese like | *[[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]]) | *Malodorous smell is unusual (if present favors diagnosis of [[Bacterial vaginosis]]) | ||
* | *Intense vulvovaginal [[pruritus]] or burning | ||
* | *Dyspareunia | ||
*[[ | *[[Dysuria]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 31: | Line 33: | ||
==Evaluation== | ==Evaluation== | ||
[[File:Vaginal wet mount of candidal vulvovaginitis.jpg|thumb|KOH test on a vaginal wet mount, showing slings of pseudohyphae of Candida albicans surrounded by round vaginal epithelial cells.]] | |||
===Work-up=== | ===Work-up=== | ||
*Wet mount | *Urine pregnancy | ||
* | *Wet mount | ||
*Consider blood glucose (if recurrent, to check for occult DM) | |||
*Consider tests for [[STIs]] | |||
===Diagnosis=== | ===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== | ==Management== | ||
*Do not treat if asymptomatic | *Do ''not'' treat if asymptomatic | ||
*Sexual partners should not be treated unless the patient has frequent recurrences | *Sexual partners should ''not'' be treated unless the patient has frequent recurrences | ||
* | *Does ''not'' need a test of cure | ||
===Antifungals=== | ===Antifungals=== | ||
| Line 54: | Line 57: | ||
==Disposition== | ==Disposition== | ||
*Outpatient | *Outpatient | ||
**Refer all "complicated" cases to gynecology | |||
==See Also== | ==See Also== | ||
Latest revision as of 22:33, 19 June 2024
Background
- 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[1]
- 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
- Vulvar pruritus - most common and specific symptom[2]
- 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
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)[3]
- 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[4]
Disposition
- Outpatient
- Refer all "complicated" cases to gynecology
See Also
References
- ↑ Adapted from ACOG practice bulletin
- ↑ Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.
- ↑ Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.
- ↑ Molgaard-Nielsen D et al. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67.