Vulvitis: Predisposing Factors, Clinical Manifestations, Diagnosis, and Treatment
Vulvitis refers to vulvar inflammation affecting the labia, clitoris, mons pubis, and vestibule of the vagina. Clinical manifestations, diagnosis, and treatment.
Candidal Vaginitis: Symptoms, Causes and Treatment
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Vaginal candidiasis (candidal vaginitis or thrush) is an inflammation of the vaginal mucosa, typically caused by Candida albicans, but may also be triggered by other species of Candida or yeasts. It is estimated that 75% of women experience at least one episode of candidal vaginitis, while 40%-45% have two or more episodes. Approximately 10%-20% of women encounter complicated candidal vaginitis that requires special diagnostic and therapeutic efforts.
Clinical presentation
The patient experiences itching, pain, swelling of the vaginal mucosa, and hyperemia, along with thick and heavy vaginal discharge. Vulvar edema, fissures, excoriations, and dysuria may be present. Based on clinical manifestations, microbiological investigation, the patient’s health status, and response to therapy, candidal vaginitis can be classified as uncomplicated or complicated.
Clinical criteria for uncomplicated candidal vaginitis:
- Sporadic or rare episodes;
- Moderate manifestations;
- Most likely caused by Candida albicans;
- Typical for women without immunosuppression.
Clinical criteria for complicated candidal vaginitis:
- Recurrent episodes of candidiasis;
- Severe manifestations of the disease;
- Not caused by Candida albicans;
- Typical for women with diabetes mellitus, immunodeficiency states (e.g., HIV infection), concomitant immunodeficiency, or receiving immunosuppressive therapy (e.g., corticosteroids).
Recurrent candidal vaginitis is diagnosed with three or more episodes of symptomatic candidal vaginitis per year. Recurrent candidal vaginitis may either be idiopathic or secondary (associated with frequent antibiotic use, diabetes, etc.). The pathogenesis of recurrence is poorly understood, and most women do not present with apparent predisposing or underlying conditions. C. glabrata and other non-albicans Candida species are found in 10–20% of women with recurrent candidal vaginitis.
Diagnosis of vaginal candidiasis
A diagnosis can be made in a woman who has signs and symptoms of vaginitis, with microscopic examination of vaginal discharge demonstrating buds, hyphae, or pseudohyphae. Candida glabrata does not form pseudohyphae or hyphae, complicating diagnosis. Candidal vaginitis does not alter the pH of the vagina (it remains at <4.5). Applying 10% KOH solution to wet preparations enhances visualization of yeasts and mycelium by breaking down cellular material, which may obscure yeast or pseudohyphae. For those with negative microscopy results but who present with signs or symptoms, a culture of vaginal discharges for Candida should be considered. If culture testing is not feasible, empirical treatment may be considered as well. The identification of Candida cultures in the absence of symptoms does not warrant treatment, as Candida and other yeasts constitute the vaginal microbiome in approximately 10–20% of women.
Differential diagnosis
Examinations with appropriate testing are crucial to determine other causes of vaginal symptoms, including sexually transmitted infections, malignant lesions of the vulva, vagina, and cervix, pelvic inflammatory disease, vulvovaginal herpes, vaginal fistulas, trauma, and vulvovaginal dermatoses.
Treatment of vaginal candidiasis
Short-term local medications (e.g., single-dose or regimens lasting 1–3 days) effectively treat uncomplicated candidal vaginitis. Treatment with azoles relieves symptoms in 80–90% of patients completing therapy.
Medications for the treatment of vaginal candidiasis
| Medication | Formulation | Dosage | Method of application |
|---|---|---|---|
| Clotrimazole | 1% cream | 5 g | Intravaginally |
| Clotrimazole | 2% cream | 5 g | Intravaginally |
| Miconazole | 2% cream | 5 g | Intravaginally |
| Miconazole | 4% cream | 5 g | Intravaginally |
| Miconazole | Vaginal suppository | 100 mg | Intravaginally |
| Miconazole | Vaginal suppository | 200 mg | Intravaginally |
| Miconazole | Vaginal suppository | 1200 mg | Intravaginally |
| Tioconazole | 6.5% ointment | 5 g | Intravaginally |
| Butoconazole | 2% cream (bioadhesive) | 5 g | Intravaginally |
| Terconazole | 0.4% cream | 5 g | Intravaginally |
| Terconazole | 0.8% cream | 5 g | Intravaginally |
| Terconazole | Vaginal suppository | 80 mg | Intravaginally |
| Fluconazole | Tablets | 150 mg | Orally |
Treatment of vaginitis associated with non-albicans Candida
Optimal treatment for these types of vaginitis remains unknown, although longer therapy durations (7–14 days) with a regimen of fluconazole and azole (either oral or local) are recommended. For recurrent cases, 600 mg of boric acid in a gelatin capsule may be administered vaginally. This treatment regimen leads to eradication in 70% of cases.
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Treatment of recurrent vulvovaginal candidiasis
Most episodes of recurrent candidal vaginitis caused by C. albicans respond well to short-term oral or local azole therapy. However, to maintain clinical control, a longer duration of initial therapy is recommended: 7–14 days of local therapy or an oral dose of fluconazole (100 mg, 150 mg, or 200 mg). To maintain remission, oral fluconazole (dose 100 mg, 150 mg, or 200 mg) is taken weekly for 6 months. If this regimen is not feasible, alternative periodic local treatment can be considered.
Treatment during pregnancy
Pregnant women are recommended only local azole therapy applied for 7 days.
FAQ
1. What is thrush, and how does it manifest?
Vaginal candidiasis is a fungal infection of the vaginal mucosa caused by yeast-like fungi of the Candida species. Typical manifestations include intense itching in the genital area, burning during urination, redness and swelling of mucous membranes, and abundant white curd-like discharge.
2. What are the main causes of thrush?
The occurrence of candidal vaginitis is associated with the active proliferation of opportunistic Candida fungi, facilitated by various factors. These include reduced immunity, prolonged antibiotic use, hormonal changes during pregnancy or oral contraceptive use, diabetes mellitus, wearing synthetic underwear, and the use of scented hygienic products.
3. How to distinguish thrush from other gynecological diseases?
Differential diagnosis is based on characteristic clinical manifestations and laboratory studies. Unlike bacterial vaginosis, candidiasis does not exhibit a strong unpleasant odor, and vaginal pH remains within the normal range (acidic environment). Accurate diagnosis requires gynecological examination and microscopic examination of a smear.
4. What treatment methods are most effective?
To treat uncomplicated forms of the disease, local antifungal medications in the form of vaginal suppositories or creams containing clotrimazole, miconazole, or nystatin should be used. Systemic therapy may include a single dose of fluconazole at 150 mg. Recurrent and complicated forms require a longer treatment course and maintenance therapy.
5. What are the risks of thrush during pregnancy?
Candidiasis during pregnancy requires mandatory treatment, as it can lead to infection of the fetus during delivery. Pregnant women are prescribed exclusively topical forms of antifungal drugs, as systemic agents might negatively affect fetal development.
6. Is thrush a sexually transmitted disease?
Although candidal vaginitis is not classified as a typical sexually transmitted disease (STD), this fungal infection can potentially be transmitted through sexual contact. Treatment of the sexual partner is required only if they exhibit clinical symptoms of the disease.
References
1.
VOKA 3D Anatomy & Pathology – Complete Anatomy and Pathology 3D Atlas [Internet]. VOKA 3D Anatomy & Pathology.
Available from: https://catalog.voka.io/
2.
Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recommendations and Reports [Internet]. 2021 Jul 22;70(4):1–187.
Available from: https://doi.org/10.15585/mmwr.rr7004a1
3.
Voidaleski MF, De Fátima Costa F, De Hoog GS, Gomes RR, Vicente VA. Metagenomics reveals an abundance of black yeast‐like fungi in the skin microbiome. Mycoses [Internet]. 2023 Feb 6;66(6):488–496.
Available from: https://doi.org/10.1111/myc.13574
4.
Gonçalves B, Ferreira C, Alves CT, Henriques M, Azeredo J, Silva S. Vulvovaginal candidiasis: Epidemiology, microbiology and risk factors. Crit Rev Microbiol. 2022;48(2):195-214. doi: 10.1080/1040841X.2021.1962801.
5.
Heath PT, Galiza EP, Baxter DN, Boffito M, Browne D, Burns F, et al. Safety and efficacy of the NVX-COV2373 Coronavirus Disease 2019 vaccine at completion of the Placebo-Controlled Phase of a randomized controlled trial. Clin Infect Dis [Internet]. 2022 Oct 10;76(3):398–407.
Available from: https://doi.org/10.1093/cid/ciac803
6.
Sobel JD, Mitchell C, Nyirjesy P, Foxman B. Treatment of vulvovaginal candidiasis: Executive summary of the 2023 clinical practice guideline. Obstet Gynecol [Internet]. 2023 May;141(5):927-935.
Available from: https://doi.org/10.1097/AOG.0000000000005154
7.
The European Society for the Study of Vulvovaginal Disease. Evidence-based guidelines for the management of vulvovaginal candidiasis. J Low Genit Tract Dis [Internet]. 2022 Jan;26(1):1-15.
Available from: https://doi.org/10.1097/LGT.0000000000000673
8.
World Health Organization. WHO guideline for the treatment of vaginal discharge. WHO Press. 2023.
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