Vulvo-Vaginal Candidiasis

Introduction

Vulvo-vaginal Candidiasis is an inflammation of the vagina and vulva,
usually evolving from vaginal discharge and secondary external irritation.
Candida albicans is the commonest cause of candidal vulvo-vaginitis; Candida glabrata has also been identified.
Candidal vaginitis is most common in:

  • Pregnancy
  • Patients with diabetes mellitus
  • Those on long-term antibiotic therapy or oral contraceptives
  • Conditions associated with immune suppression
  • Corticosteroid use

Usually not acquired through sexual intercourse. Because of the close proximity between the anus and female genitalia, re-infections may occur from the gastrointestinal tract

Clinical features

  • Up to 20% of women with the infection may be asymptomatic
  • If symptoms occur, they usually consist of vulval itching, soreness and a non-offensive
  • vaginal discharge which may be curdy

Clinical examination:

  • Vulval erythema (redness) or excoriations from scratching
  • Vulval oedema
  • Erosions and crusting on the adjacent intertriginous skin
  • Although treatment of sexual partners is not recommended, it may be considered for women who have recurrent infections
  • A minority of male partners may have balanitis, which is characterized by erythema
    of the glans penis or inflammation of the glans penis and foreskin (balanoposthitis)

Differential diagnoses

  • Other causes of vaginal discharge in women see Gonorrhoea

Complications

  • Emotional problems because of the
    recurrent nature of the infection, and dyspareunia
  • Very serious emotional problems in a non sexually active person wrongly “accused” by
    parents, spouse or health care providers

Investigations

  • Positive KOH examination
  • Culture of vaginal discharges

Treatment objectives

  • Cure the infection
  • Prevent recurrence

Drug therapy

Recommended regimen:

  • Clotrimazole 1% vaginal cream: Insert 5 g at night as a single dose; may be repeated once if necessary

Or:

  • Miconazole 2% intravaginal cream:
    Insert 5 g once daily for 10-14 days or twice daily for 7 days

Or:

  • Clotrimazole 500 mg intravaginally, as a single dose

Or:

  • Fluconazole 150 mg orally, as a single dose

Recommended topical regimen for balanoposthitis

  • Clotrimazole 1% cream apply twice daily for 7 days
  • Miconazole 2% cream twice daily for 7 days

Or:

Notable adverse drug reactions, caution and contraindications

Fluconazole:

  • Caution in patients with renal impairment
  • Avoid in pregnancy and breastfeeding
  • Monitor liver function
  • Discontinue if signs or symptoms of
    hepatic disease develop (risk of hepatic necrosis)
  • May cause nausea, abdominal
    discomfort, diarrhoea, flatulence,
    headache, skin rash and Steven-Johnson syndrome
  • Discontinue treatment or monitor closely if infection is invasive or systemic)

Prevention

  • Reduce or eliminate predisposing factors
  • After defecation, cleaning should be done backwards to prevent faecal contamination of the vulva and vagina