Candidal vulvovaginitis

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Candidal vulvovaginitis
Classification and external resources
Vaginal wet mount of candidal vulvovaginitis.jpg
Vaginal wet mount showing slings of pseudohyphae of Candida albicans surrounded by round vaginal epithelial cells, conferring a diagnosis of candidal vulvovaginitis.
ICD-10 B37.3, N77.1
ICD-9 112.1, 616.1
MedlinePlus 001511
MeSH D002181

Candidal vulvovaginitis or vaginal thrush is an infection of the vagina’s mucous membranes by Candida albicans.[1] 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.[2] Clothing and personal hygiene are not factors.[2]

Treatment is with an antifungal medication.[3] This may be either topical such as clotrimazole or oral such as fluconazole.[3] Probiotics have not been found to be useful for active infections.[4]

Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes.[5] It is the second most common cause of vaginal inflammation after bacterial vaginosis.[6]

Signs and symptoms[edit]

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.[7] 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).[8]

Cause[edit]

While vulvovaginal candidiasis is caused by the yeast Candida, there are many predisposing factors.[2] 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.[9]

Medications[edit]

Infection occurs in about 30% of women who are taking a course of antibiotics by mouth.[2] The evidence of the effect of oral contraceptives is controversial.[2]

Pregnancy[edit]

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.[2] There is no clear evidence that treatment of asymptomatic candidal vulvovaginitis in pregnancy reduces the risk of preterm birth.[10]

Lifestyle[edit]

Infections often occur without sex and cannot be related to frequency of intercourse.[2] Personal hygiene methods or tight-fitting clothing, such as tights and thong underwear, do not appear to increase the risk.[2]

Diseases[edit]

Those with poorly controlled diabetes have increased rates of infection while those with well controlled diabetes do not.[2]

The risk of developing thrush is also increased in an immunodeficiency,[8] 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.

Diagnosis[edit]

Vulvovaginal candidosis is the presence of Candida in addition to vaginal inflammation.[6] The presence of yeast is typically diagnosed in one of three ways: microscopy, microbial culture, and antigen tests.[6] It may be described as being uncomplicated or complicated.

Uncomplicated[edit]

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[edit]

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.[8]

Treatment[edit]

Following are alternatives of recommended regimens:

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.[3]

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.[8]

Recurrent episodes[edit]

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.[12][13] 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 o 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).[14][15]

For infrequent recurrences, the simplest and most cost-effective management is self-diagnosis and early initiation of topical therapy.[16] 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.[3] 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.[3]

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.[17] Preventive maintenance treatment may be recommended after more than four episodes per year, such as by fluconazole orally once per week for 6 months.[17] About 10-15% of recurrent candidal vulvovaginitis cases are due to non-Candida albicans species.[18] Non-albicans species tend to have higher levels of resistance to fluconazole.[19] Therefore, recurrence or persistence of symptoms while on treatment indicates speciation and antifungal resistance tests to tailor antifungal treatment.[17]

Alternative medicine[edit]

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.[20] No benefit has been found for active infections.[4]

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.

Epidemiology[edit]

Candidiasis is one of the three most common vaginal infections along with bacterial vaginosis and trichomonas.[6] Approximately 20% of women get an infection yearly.[6] It is believed that 70–75% of women have at least one infection in their lifetime.[2]

References[edit]

  1. ^ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. p. 309. ISBN 0-7216-2921-0. 
  2. ^ a b c d e f g h i j Sobel, JD (9 June 2007). "Vulvovaginal candidosis.". Lancet 369 (9577): 1961–71. doi:10.1016/S0140-6736(07)60917-9. PMID 17560449. 
  3. ^ a b c d e f g Workowski KA, Berman SM (August 2006). "Sexually transmitted diseases treatment guidelines, 2006". MMWR Recomm Rep 55 (RR-11): 1–94. PMID 16888612. 
  4. ^ a b Abad, CL; Safdar, N (June 2009). "The role of lactobacillus probiotics in the treatment or prevention of urogenital infections – a systematic review.". Journal of chemotherapy (Florence, Italy) 21 (3): 243–52. doi:10.1179/joc.2009.21.3.243. PMID 19567343. 
  5. ^ Egan ME, Lipsky MS (September 2000). "Diagnosis of vaginitis". Am Fam Physician 62 (5): 1095–104. PMID 10997533. 
  6. ^ a b c d e Ilkit, M; Guzel, AB (August 2011). "The epidemiology, pathogenesis, and diagnosis of vulvovaginal candidosis: a mycological perspective". Critical reviews in microbiology 37 (3): 250–61. doi:10.3109/1040841X.2011.576332. PMID 21599498. 
  7. ^ Mendling, W; Brasch, J; German Society for Gynecology and, Obstetrics; Working Group for Infections and Infectimmunology in Gynecology and, Obstetrics; German Society of Dermatology, the Board of German, Dermatologists; German Speaking Mycological, Society (July 2012). "Guideline vulvovaginal candidosis (2010) of the German Society for Gynecology and Obstetrics, the Working Group for Infections and Infectimmunology in Gynecology and Obstetrics, the German Society of Dermatology, the Board of German Dermatologists and the German Speaking Mycological Society.". Mycoses. 55 Suppl 3: 1–13. doi:10.1111/j.1439-0507.2012.02185.x. PMID 22519657. 
  8. ^ a b c d 'Thrush, vaginal', NHS Choices A-Zhttp://www.nhs.uk/Conditions/Thrush/Pages/Prevention.aspx
  9. ^ Sobel, Jack. "Vulvovaginal Candidiasis". UpToDate. Retrieved 26 February 2012. 
  10. ^ Roberts, C. L.; Rickard, K.; Kotsiou, G.; Morris, J. M. (2011). "Treatment of asymptomatic vaginal candidiasis in pregnancy to prevent preterm birth: An open-label pilot randomized controlled trial". BMC Pregnancy and Childbirth 11: 18. doi:10.1186/1471-2393-11-18.  edit
  11. ^ Candida - female genital, Managing infection in pregnancy, from National Institute for Health and Care Excellence. Last revised in August 2012.
  12. ^ obel JD. Epidemiology and pathogen- esis of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol 1985;152:924-35.
  13. ^ Spinillo A, Pizzoli G, Colonna L, Nicola S, De Seta F, Guaschino S. Epidemiologic characteristics of women with idiopathic recurrent vulvovaginal candidiasis. Obstet Gynecol 1993;81:721-7
  14. ^ Fidel PL Jr, Sobel JD. Immunopathogen- esis of recurrent vulvovaginal candidiasis. Clin Microbiol Rev 1996;9:335-48.
  15. ^ Maintenance Fluconazole Therapy for Recurrent Vulvovaginal Candidiasis Jack D. Sobel, M.D., Harold C. Wiesenfeld, M.D., Mark Martens, M.D., Penny Danna, M.D., Thomas M. Hooton, M.D., Anne Rompalo, M.D., Malcolm Sperling, M.D., Charles Livengood III, M.D., Benson Horowitz, M.D., James Von Thron, M.D., Libby Edwards, M.D., Helene Panzer, Ph.D., and Teng-Chiao Chu, Ph.D.n New engl j med 351;9 www.nejm.org august 26, 2004
  16. ^ Ringdahl, EN (Jun 1, 2000). "Treatment of recurrent vulvovaginal candidiasis.". American family physician 61 (11): 3306–12, 3317. PMID 10865926. 
  17. ^ a b c Ramsay, Sarah; Astill, Natasha; Shankland, Gillian; Winter, Andrew (November 2009). "Practical management of recurrent vulvovaginal candidiasis". Trends in Urology, Gynaecology & Sexual Health 14 (6): 18–22. doi:10.1002/tre.127. 
  18. ^ Sobel, JD (2003). "Management of patients with recurrent vulvovaginal candidiasis.". Drugs 63 (11): 1059–66. doi:10.2165/00003495-200363110-00002. PMID 12749733. 
  19. ^ Sobel, JD (1988). "Pathogenesis and epidemiology of vulvovaginal candidiasis.". Annals of the New York Academy of Sciences 544: 547–57. doi:10.1111/j.1749-6632.1988.tb40450.x. PMID 3063184. 
  20. ^ Jurden, L; Buchanan, M; Kelsberg, G; Safranek, S (June 2012). "Clinical inquiries. Can probiotics safely prevent recurrent vaginitis?". The Journal of family practice 61 (6): 357, 368. PMID 22670239.