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Candidal vulvovaginitis or vaginal thrush is an infection of the vagina’s mucous membranes by Candida albicans. Signs and symptoms include: vaginal itching or pain, burning with urination and vaginal discharge that typically does not smell.
It is most commonly caused by excessive growth of one of a family of fungus known as Candida. They are normally present in the vagina in small numbers and usually harmless. It is not known exactly how changes in the vagina trigger thrush, but it may be due to a hormone (chemical) imbalance. In most cases, the cause of the hormonal changes is unknown. Risk factors include taking antibiotics. Clothing and personal hygiene are not factors.
Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes. It is the second most common cause of vaginal inflammation after bacterial vaginosis.
Signs and symptoms
The symptoms of vaginal thrush include vulval itching, vulval soreness and irritation, pain or discomfort during sexual intercourse (superficial dyspareunia), pain or discomfort during urination (dysuria) and vaginal discharge, which is usually odourless. This can be thin and watery, or thick and white, like cottage cheese.
As well as the above symptoms of thrush, vulvovaginal inflammation can also be present. The signs of vulvovaginal inflammation include erythema (redness) of the vagina and vulva, vagina fissuring (cracked skin), edema (swelling from a build-up of fluid), also in severe cases, satellite lesions (sores in the surrounding area). This is rare, but may indicate the presence of another fungal condition, or the herpes simplex virus (the virus that causes genital herpes).
While vulvovaginal candidiasis is caused by the yeast Candida, there are many predisposing factors. Symptoms of thrush can also be caused by Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis. Non-albican Candida are commonly found in complicated cases of vaginal thrush such that first line treatment is ineffective. These cases are more likely in those who are immunocompromised.
In pregnancy, changes in the levels of female sex hormones, such as estrogen, make a woman more likely to develop a yeast infection. During pregnancy, the Candida fungus is more prevalent (common), and recurrent infection is also more likely. There is no clear evidence that treatment of asymptomatic candidal vulvovaginitis in pregnancy reduces the risk of preterm birth.
Infections often occur without sex and cannot be related to frequency of intercourse. Personal hygiene methods or tight-fitting clothing, such as tights and thong underwear, do not appear to increase the risk.
The risk of developing thrush is also increased in an immunodeficiency, for example, by an immunosuppressive condition, such as HIV or AIDS, or receiving chemotherapy. This is because in these circumstances the body's immune system, which usually fights off infection, is unable to effectively control the spread of the Candida fungus.
Vulvovaginal candidosis is the presence of Candida in addition to vaginal inflammation. The presence of yeast is typically diagnosed in one of three ways: vaginal wet mount microscopy, microbial culture, and antigen tests. It may be described as being uncomplicated or complicated.
Uncomplicated thrush is where only a single episode of thrush or less than four episodes occurs in a year. Thrush is described as uncomplicated if the symptoms are mild or moderate, and caused by the Candida albicans fungus.
Complicated thrush is four or more episodes of thrush in a year or when severe symptoms of vulvovaginal inflammation are experienced. Thrush may also be described as complicated if coupled with pregnancy, poorly controlled diabetes, an immune deficiency, or the thrush is not caused by the Candida albicans fungus.
Following are alternatives of recommended regimens:
- Intravaginal agents: butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole. Candidal vulvovaginitis in pregnancy should be treated with intravaginal clotrimazole or miconazole for at least 7 days.
- Oral Agent: fluconazole as a single dose.
Short-course topical formulations (i.e., single dose and regimens of 1–3 days) effectively treat uncomplicated candidal vulvovaginitis. The topically applied azole drugs are more effective than nystatin. Treatment with azoles results in relief of symptoms and negative cultures in 80–90% of patients who complete therapy.
The creams and suppositories in this regimen are oil-based and might weaken latex condoms and diaphragms. Treatment for vagina thrush using antifungal medication is ineffective in up to 20% of cases. Treatment for thrush is considered to have failed if the symptoms do not clear within 7–14 days. There are a number of reasons for treatment failure. For example, if the infection is a different kind, such as bacterial vaginosis (the most common cause of abnormal vaginal discharge), rather than thrush.
About 5-8% of the reproductive age female population will present four or more episodes per year, those patients are diagnosed with recurrent vulvovaginal candidiasis. The cause of recurrent infections is unknown. The most supported theory for the production of recurrent infections states that since vaginal and gut colonization with candida is normal or very commonly seen in patients with no recurrent infections, this patients could have a hypersensitivity to candida that makes them react overtly with activation of the local immune system. Candida antigens are presented to antigen presenter cells that react with citokine production that activate lymphocytes and Neutrophils that lead to Inflammation and edema. This theory is partly supported by evidence that shows that treatment with anti fungal medications in a weekly basis avoids recurrence in most of patients when those medications are prescribed for long periods of time (up to six months).
For infrequent recurrences, the simplest and most cost-effective management is self-diagnosis and early initiation of topical therapy. However, women whose condition has previously been diagnosed with candidal vulvovaginitis are not necessarily more likely to be able to diagnose themselves; therefore, any woman whose symptoms persist after using an over the counter preparation, or who has a recurrence of symptoms within 2 months, should be evaluated with office-based testing. Unnecessary or inappropriate use of OTC preparations is common and can lead to a delay in the treatment of other vulvovaginitis etiologies, which can result in adverse clinical outcomes.
When there are more than four recurrent episodes of candidal vulvovaginitis per year, a longer initial treatment course is recommended, such as orally administered fluconazole followed by a second and third dose 3 and 6 days later, respectively. Preventive maintenance treatment may be recommended after more than four episodes per year, such as by fluconazole orally once per week for 6 months. About 10-15% of recurrent candidal vulvovaginitis cases are due to non-Candida albicans species. Non-albicans species tend to have higher levels of resistance to fluconazole. Therefore, recurrence or persistence of symptoms while on treatment indicates speciation and antifungal resistance tests to tailor antifungal treatment.
There is not enough evidence to determine if probiotics (either as pills or as yogurt) has an effect on the rate of occurrence of vaginal yeast infections. No benefit has been found for active infections.
Special cleansing diets and colonic hydrotherapy have been proposed as solutions for the chronic gut colonization of candida, but no scientific evidence for this methods is available at this time.
Candidiasis is one of the three most common vaginal infections along with bacterial vaginosis and trichomonas. Approximately 20% of women get an infection yearly. It is believed that 70–75% of women have at least one infection in their lifetime.
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