Vulvovaginitis, candidal

Vulvovaginitis (also Vulvitis) 616.10
Vulvovaginitis, amebic 006.8
Vulvovaginitis, chlamydial 099.53
Vulvovaginitis, gonococcal (acute) 098.0
Vulvovaginitis, gonococcal, chronic or duration of 2 months or over 098.2
Vulvovaginitis, herpetic 054.11
Vulvovaginitis, monilial 112.1
Vulvovaginitis, trichomonal (Trichomonas vaginalis) 131.01

DESCRIPTION
Vulvar pruritus and/or burning, often with abnormal vaginal discharge

System(s) affected: Reproductive, Skin/Exocrine

Genetics: N/A

Incidence/Prevalence in USA:

  • 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

    Provided by ArmMed Media
    Revision date: June 22, 2011
    Last revised: by Sebastian Scheller, MD, ScD