Candida vulvovaginitis

Background

  • Local fungal infection caused by the Candida genus
  • 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)

Types

  • Uncomplicated
    • Sporadic infectionn
    • mild-moderate symptoms
    • due to Candida albicans
    • immunocompetent
  • Complicated
    • Recurrent infection
    • severe symptoms
    • uncontrolled DM
    • immunosuppression
    • pregnant

Clinical Features[1]

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

Evaluation

Work-up

  • Wet mount - shows hyphae and yeast buds
    • Candida does not cause WBCs on wet mount → if present, consider co-infection with other vaginitides or STI
  • If recurrent, consider checking blood glucose for occult DM

Diagnosis

  • although other candida infections are clinically diagnosed, laboratory methods should be pursued to confirm diagnosis of candida vulvovaginitis
  • cotton cheese curd-like non-odorous vaginal discharge on pelvic exam
  • vaginal pH < 4.5
  • vaginal wet mount

Management

  • Do not treat if asymptomatic
  • Sexual partners should not be treated unless the patient has frequent recurrences
  • Antifungal[2]
    • 1st line: Oral Fluconazole
    • Pregnant: Topical imidazole (clotrimazole, miconazole)

Antifungals

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

Oral Therapy

  • Fluconazole 150mg PO once
    • a second dose at 72hrs can be given if patient is still symptomatic

Pregnant Patients

  • Intravaginal Clotrimazole or Miconazole are the only recommended treatments
  • Duration is 7 days
  • PO fluconazole associated with congenital malformations and spontaneous abortions[3]

Disposition

  • Outpatient

See Also

References

  1. Kauffmann CA. Overview of Candida Infections. UptoDate. 2016.
  2. 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.
  3. 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.

Authors:

Ross Donaldson