40% of vulvovaginitis is caused by Candida

16% of non-pregnant premenopausal women are asymptomatic carriers

Predominant age: Menarche to menopause

Predominant sex: Female only

SIGNS AND SYMPTOMS

Intense vulvar itching

Thick curd-like vaginal discharge

Dyspareunia at times

Erythema of vulva

Erythema, pain and pruritus of crural and perineal area

Thick white patches appear attached to vaginal mucosa

Inflamed vulvar skin

CAUSES

Overgrowth of Candida species (C. albicans, C. glabrata, C. tropicalis) in vagina

RISK FACTORS

Pregnancy

Diabetes mellitus

Antibiotic therapy

Corticosteroid therapy

Immunosuppressed states

HIV infection

Occlusive synthetic underpants and undergarments

Hypothyroidism

Oral contraceptive medications (low dose usually not a cause of increased infection risk)

Anemia

Zinc deficiency

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

Trichomonas vaginitis

Gonorrheal vaginitis - in prepubertal girls

Pinworm vaginitis

Contact dermatitis/vaginitis

LABORATORY

Yeast, spores, and/or pseudohyphae on smear with 10% KOH solution

Culture findings on Nickerson’s or Sabouraud’s media; usually only indicated for recurrent infections

Vaginal pH < 4.5

DIAGNOSTIC PROCEDURES

Smear of discharge with 10% KOH solution

Pap smear

TREATMENT

APPROPRIATE HEALTH CARE
Outpatient

GENERAL MEASURES

Remove foreign body if one present

Consider povidone-iodine (Betadine, Operand) douche 15 to 30 mL/L (2 tbsp/qt) of water for symptomatic relief until specific therapy is effective

If urination causes burning, have the patient

 
• Urinate through a tubular device such as a toilet-paper roll or plastic cup with the end cut out  
• Pour warm water over vaginal area while urinating

Insist on strict diabetic control if patient is diabetic

ACTIVITY

Avoid overexertion, heat, and excessive sweating

Delay sexual relations until symptoms clear

DIET
Limit sweets (sucrose) and dairy products (lactose) in recurrent infections

PATIENT EDUCATION

Keep the genital area clean. Use plain unscented soap.

Take showers rather than tub baths

Wear cotton underpants with a cotton crotch. Avoid clothing made from non-ventilating materials, including most synthetic underclothing. Avoid tight-fitting jeans or slacks

Sleep in loose gown without underpants

Don’t sit around in wet clothing - especially a wet bathing suit

Avoid frequent douches

Avoid broad-spectrum antibiotics when possible

After urinating or bowel movements, cleanse by wiping or washing from front to back (vagina toward anus)

Lose weight, if obese

American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG

MEDICATIONS

DRUGS OF CHOICE

Fluconazole (Diflucan): 150 mg po once

Miconazole nitrate (Monistat): one suppository q night x 3, or miconazole vaginal cream q night x 7, or

Butoconazole nitrate (Femstat): vaginal cream q night x 3, or

Terconazole (Terazol): one suppository or vaginal cream q night x 3, or

Clotrimazole (Gyne-Lotrimin): two 100 mg tablets intravaginally x 3 days or cream each night x 7 days

Contraindications: N/A

Precautions:

Use fluconazole with caution in patients with liver disease

Significant possible interactions: Refer to manufacturer’s profile of each drug

ALTERNATIVE DRUGS

Retreat with different agent, if recurrence

Course of oral nystatin; 100,000 units tid for 2 weeks

Topical gentian violet 1% aqueous solution painted onto vagina weekly until infection resolves (usually 2-3 weeks)

Boric acid 600 mg in gelatin capsule inserted vaginally daily for 2 weeks.

FOLLOWUP

PATIENT MONITORING
Generally no specific followup needed. If symptoms persist, then repeat pelvic exam and culture.

PREVENTION/AVOIDANCE

Follow instructions under patient education

For recurrences consider reinfection from sexual partner(s). Examine and treat sex partner for Candida balanitis and oral Candida if vaginitis recurs.

Review Risk Factors

POSSIBLE COMPLICATIONS
Secondary bacterial infections of the vagina or vulva

EXPECTED COURSE/PROGNOSIS

Complete cure with vigorous treatment

Recurrences are common

MISCELLANEOUS

ASSOCIATED CONDITIONS
Sexually transmitted diseases

AGE-RELATED FACTORS

Pediatric: Less common before puberty

Geriatric: N/A

Others: N/A

PREGNANCY
Common

SYNONYMS

Monilial vulvovaginitis

ICD-9-CM
112.1 Candidiasis of vulva and vagina

Author(s)
Albert T. Shiu, MD