creation date: 2024-12-29 14:09
tags: Pathologies
Vaginal Candidiasis
Background
Definitions
Characterized by inflammation of the vulva and vagina due to Candida species resulting in common vaginitis symptoms. Vaginal candidiasis is also commonly referred to as an yeast infection.
Etiology and Pathgenesis
Candida albicans is responsible for majority of vaginal candidiasis cases. The remainder are due to nonalbicans Candida species.
Colonization is likely due to migration from the rectum and very rarely sexually transmitted or from a vaginal reservoir. The transformation from asymptomatic colonization to symptomatic is complex but requires overgrowth and penetration of superficial epithelial cells.
While infection can occur sporadically, a number of triggers are discussed below.
Clinical Presentation
Signs & Symptoms
Vulvar pruritus is the dominant feature but a number of symptoms are often present including:
- Vulvar burning
- Soreness
- Irritation
- Dysuria (often perceived as external rather than urethral)
Patients may report vaginal discharge. When present, it is classically white, thick, adherent to the vaginal sidewalls, and clumpy. Often described as “curd-like” or “cottage cheese-like”. There may be no or minimal odour.
History & Physical Exam
Physical examination of external genitalia, vagina, and cervix may reveal erythema and edema. There may also be non-specific inflammatory changes such as excoriation and fissures.
A sample of vaginal discharge is collected for testing which is discussed below.
Risk factors
- Diabetes mellitus - poor glycemic control and/or use of SGLT2i may contribute to risk
- Antibiotic use - as many as one-third of women who use of broad-spectrum antibiotics develop VC after
- Increased estrogen - such as in pregnancy or during postmenopausal estrogen therapy
- Immunosuppression
- Genetics
Diagnosis
Criteria
Diagnosis is made by confirming the presence of Candida.
It should be noted that Candida species are part of the normal flora of 25% of women and as such, presence alone is not indicative of disease
Work-up
Tests which confirm or support the diagnosis include:
- Vaginal pH - with Candida infection, pH is normal (4-4.5)
- Microscopy - can identify Candida; 10% KOH can emphasize Candida cells
- Whiff test - would be negative with application of KOH
- Nucleic acid amplification tests - definitive diagnosis
Note that cultures are not required nor routine. They may be considered if another pathogen is suspected or no Candida was found with other tests.
Differential
If pH is normal:
- Hypersensitivity reactions
- Allergic or chemical reaction
- Contact dermatitis
- Neuropathic itch
- Inflammatory dermatoses
If pH is elevated:
- Bacterial vaginosis (+ positive Whiff test)
- Trichomoniasis
Note that mixed infection with other pathogens is possible and common.
Red Flags / Complications
Complications are rare. With severe cases, infection may cause extensive vulvar erythema, edema, excoriation, and fissures.
Other complications may be related to treatment.
Management
Lifestyle / Social
General recommendations to prevent recurrent infection include:
- Keep vaginal area dry
- Avoiding soap in vulvovaginal area
- Avoiding douches
Consider counselling regarding sexual dysfunction in addition to the infection.
Pharmacological / Interventional
Medication regime depends on the complexity. The criteria for uncomplicated infection requires all of the following to be fulfilled:
- Sporadic, infrequent episodes (<3 episodes/yr)
- Nonpregnant
- Mild to moderate symptoms
- Probable infection with Candida albicans (90%)
- Immunocompetent
In such cases, oral azoles, topical azoles, and triterpenoids are all reasonable choices. Common options are:
- Fluconazole 150mg PO once or twice
- Canesten internal cream
In complicated infections, regime and medication selection may be modified based on specifics. For example, using a topical azole for pregnant women.
Antifungals are discussed separately.