Continuing Education Activity
Vulvovaginitis, or inflammation of the vulva and vagina, most commonly occurs in reproductive-aged women and is usually secondary to infection. Candidal vulvovaginitis is responsible for about one-third of cases. This activity reviews the evaluation and management of candidal vulvovaginitis and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.
- Describe the epidemiology of vulvovaginitis.
- Review the presentation of vulvovaginitis
- Summarize the treatment options for vulvovaginitis.
- Outline interprofessional team strategies for improving care coordination and communication to advance care and outcomes in patients with vulvovaginitis.
Vaginal complaints are common. Vulvovaginitis, or inflammation of the vulva and vagina, is most commonly secondary to infectious agents in reproductive-aged women. Candidal vulvovaginitis is responsible for about one-third of cases.
Candidal vulvovaginitis is caused by inflammatory changes in the vaginal and vulvar epithelium secondary to infection with Candida species, most commonly Candida albicans. Candida is part of the normal flora in many women and is often asymptomatic. Therefore, candidal vulvovaginitis requires both the presence of candida in the vagina/vulva as well as the symptoms of irritation, itching, dysuria, or inflammation.
Candidal vulvovaginitis is common. It is responsible for a third of all cases of vulvovaginitis in reproductive-aged women, and 70% of women report having had candidal vulvovaginitis at some point in their lifetimes. About 8% of women suffer recurrent candidal vulvovaginitis. The most common responsible pathogen is C. albicans (in about 90% of cases), with most of the remaining cases caused by Candida glabrata. It is important to recognize that detailed epidemiological data is not available for this disease process. Because of the wide availability of over-the-counter treatments, many patients with candidal vulvovaginitis likely do not present for care. Furthermore, diagnosis is based on both clinical and ancillary evaluation, and therefore, epidemiologic reports based on culture alone overestimate disease, as 10% of women are asymptomatic with positive candidal cultures. Finally, studies demonstrate that self-diagnosis is not accurate, so data derived from a patient query are likely somewhat inaccurate.
Recognized risk factors for acute candidal vulvovaginitis include estrogen use, elevated endogenous estrogens (from pregnancy or obesity), diabetes mellitus, immunosuppression (i.e., patients with chemotherapy or antimetabolite medications, HIV infection, or transplant patients), and broad-spectrum antibiotic use. Although candidal vulvovaginitis is more common in women who are sexually active, there is no evidence that candidal infection is sexually transmitted. Patients with recurrent candidal vulvovaginitis (defined as four or more episodes of culture-proven candidal vulvovaginitis) have predisposing genetic factors that cause them to be susceptible to recurrent fungal infections. These factors may also predispose to a hypersensitivity to Candida.
Candidal vulvovaginitis occurs when Candida species superficially penetrate the mucosal lining of the vagina and cause an inflammatory response. The dominant inflammatory cells are typically polymorphonuclear cells and macrophages. Patients may present with discharge, which is typically thick and adherent, or with excoriations, "external" dysuria, vaginal itching, vaginal burning, dyspareunia, or swelling.
History and Physical
Patients typically complain of irritation, itching, and burning. Symptoms are often prominent just before the patient's menstrual period. Many patients will have a history of similar symptoms, and some will have attempted over the counter treatment with topical agents or alternative therapies. On exam, the clinician will often encounter vulvar and vaginal erythema, excoriations, thick white adherent discharge, and swelling. Some patients will have little to no discharge. The provider should not encounter ulcers, asymmetric swelling/masses, or foreign bodies. The degree of irritation is typically severe in patients with acute vulvovaginal candidiasis. Patients with infection with Candida glabrata usually have less severe symptoms. There is much overlap in the presentation of patients with vulvovaginal candidiasis versus other forms of vaginitis or cervicitis, and therefore ancillary testing, including wet mount, whiff testing, and pH testing, should be performed to make this diagnosis.
To diagnose this condition, the provider should perform a pelvic exam, a vaginal wet prep, pH testing, and testing to exclude other etiologies of vaginal discharge and infection (specifically gonococcal and chlamydial disease). In patients with candidal vulvovaginitis, inflammation is evident during a pelvic exam. However, the cervix is typically normal and not inflamed. The patient should not have cervical motion tenderness, and there should be no abnormal discharge from the cervical os. In patients with vulvovaginal candidiasis, the vaginal pH is typically less than 5. On wet prep, the provider should see lactobacillus as the prominent bacteria present, and will also likely see inflammatory cells. The patient should have a negative Whiff test (a fishy odor when potassium hydroxide is applied to the discharge on a slide). After potassium hydroxide application, the provider may see budding yeast, hyphae, or pseudohyphae on microscopy.
Vaginitis may be secondary to more than one etiology, and therefore the provider should be vigilant to the presence of clue cells (representative of bacterial vaginosis) or trichomonads (representative of trichomoniasis) on wet prep.
Most infections are secondary to Candida albicans, and if the provider sees budding yeast in the clinical setting of a reproductive age woman presenting with vulvovaginitis, there is no need to perform confirmatory cultures for Candida (although a DNA probe for sexually transmitted infections is often still appropriate). Since Candida species are part of normal vaginal flora in many women, routine cultures in asymptomatic women are also discouraged. In women with repeated episodes of candidal vulvovaginitis, culture should be obtained to identify the fungal species that may be resistant to typical empiric therapy or to identify alternative causes of vaginitis.
Treatment / Management
Acute candidal vulvovaginitis is treated with antifungal agents. Since most cases of candidal vulvovaginitis are secondary to C. albicans species, and since C. albicans does not have significant resistance to azole antifungals, these are the agents of choice for this disease. Antifungals may be taken orally as a single dose (fluconazole 150 mg) or can be applied intravaginally in a single day or 3-day regimens that are available over the counter. In patients with uncomplicated disease (those without immunosuppression or pregnancy who do not have recurrent candidal vulvovaginitis) either therapy is equally efficacious. Therefore, treatment decision may be made based on cost, patient preference, and drug interactions. If patients do not respond to standard therapy, cultures may be warranted to look for other species of candida, which are often resistant to azoles.
Patients with complicated candidal vulvovaginitis, for example those patients who are .immunosuppressed, require longer therapy. Typically, therapy includes intravaginal azole therapy for at least 1 week, or oral treatment with fluconazole 150 mg (renally adjusted for CrCl <50 ml/min) once every 3 days for three doses. Patients with recurrent candidal vulvovaginitis may benefit from suppressive therapy with weekly oral fluconazole for 6 months. Pregnant patients should not be given oral antifungals. In these patients, a 7-day course of intravaginal therapy is appropriate. Fluconazole is considered safe in breastfeeding women.
There is inadequate evidence to recommend intravaginal or oral yogurt therapy, intravaginal garlic, or douching.
Pearls and Other Issues
Although vaginitis is not a dangerous disease, it can be disabling and upsetting to patients. It is important to address social issues and sexual dysfunction in addition to the infection itself.
It is also important to maintain a broad differential diagnosis. Trauma, abuse, foreign body, malignancy, immune diseases, inflammatory bowel disease, and sexually transmitted infections can all present with vaginal discomfort. The provider should always perform a careful and complete physical exam, appropriate ancillary testing as described above, and further testing if treatment failure occurs.
Enhancing Healthcare Team Outcomes
Candida vulvovaginitis is usually managed by the gynecologist, nurse practitioner, primary care provider or an internist. The condition is clinically diagnosed and management is with antifungal medications. Most simple cases resolve within days. Patients with complicated candidal vulvovaginitis require longer therapy. Pregnant patients should not be given oral antifungals. In these patients, a 7-day course of intravaginal therapy is appropriate. Fluconazole is considered safe in breastfeeding women. There is inadequate evidence to recommend intravaginal or oral yogurt therapy, intravaginal garlic, or douching.
At the same time patient education is important. The condition is not life threatening but can be associated with embarrassment and withdrawal from sexual activities. It is also important to maintain a broad differential diagnosis. Trauma, abuse, foreign body, malignancy, immune diseases, inflammatory bowel disease, and sexually transmitted infections can all present with vaginal discomfort. The provider should always perform a careful and complete physical exam, appropriate ancillary testing as described above, and further testing if treatment failure occurs.