Vulvo-Vaginal Candidiasis

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Introduction

  • 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: see Gonorrhoea in women

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 goals

  • Cure the infection
  • Prevent recurrence

Drug treatment

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 applicator 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

Or:

Miconazole 2% cream twice daily for 7 days

Notable adverse drug reactions, contraindications and caution

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