Gulshan Sethi Vulvovaginal candidiasis (VVC) is a very common problem and one that many women will treat with over‐the‐counter preparations without seeking medical advice. Candidiasis is the second most common vaginal infection in the Western hemisphere after bacterial vaginosis [1]. Candida species are recognised as part of the normal endogenous yeast microbiota of the vulva and vagina in women of childbearing age and can be routinely isolated in up to 50% of women [2]. Approximately 75% of women of reproductive age will experience at least one episode of Candida vulvovaginitis in their lifetime [3]. However, 10–20% of women with positive vaginal cultures for Candida will be asymptomatic [4]. VVC is rare before menarche and has its highest incidence in the third and fourth decades. Candida albicans is responsible for almost 90% of symptomatic episodes of vulvovaginitis [5]. C. albicans is an ovoid, budding yeast, which, under the microscope, may be seen as spores or hyphae (Figure 10.1). Other Candida species such as C. glabrata, C. tropicalis, C. parapsilosis, and C. krusei may also cause symptoms and may be resistant to conventional anti‐candidal preparations. There is little evidence to suggest that modification of carbohydrate intake has any impact on the incidence of VVC in non‐diabetic women [6,7]. Although most women report an increase in the frequency of VVC coincident with the onset of sexual activity, it is not considered to be a sexually transmitted disease. Treatment of the male partners of women with VVC does not prevent infection in women. Figure 10.1 C. albicans spores and hyphae. Source: Published in Wisdom, A. and Hawkins, D. (1997) Diagnosis in Color: Sexually Transmitted Diseases, 2nd edn. Mosby‐Wolfe, London; slide 251, p. 148, © Elsevier 1997. The predominant symptom of VVC is pruritus. This may be intense and is usually accompanied by a thick, ‘cottage‐cheese’ like discharge which generally does not have an odour. Burning, dysuria, and superficial dyspareunia are also common. In women with vulvovaginitis, individual symptoms and signs of vaginitis in the absence of laboratory tests are unreliable diagnostic indicators of candidiasis [8]. Several studies have shown that a presumed diagnosis of Candida vulvovaginitis in women with symptoms of pruritus, burning, and discharge is inaccurate in 30% of women and leads to inappropriate treatment [9,10]. It is therefore ideal to confirm the diagnosis with swabs. There may be erythema and swelling of the vulva with excoriation and fissuring. A thick cheesy discharge may be seen at the introitus. Some patients develop severe inflammatory change which can spread out to the labia (Figure 10.2). Speculum examination reveals erythema of the vaginal walls with adherent plaques of white exudate. Erythema may extend outwards and involve the perineum and perianal area. Measurement of the pH of vaginal secretions may be helpful in distinguishing VVC from other causes of vulvovaginitis, as it is generally normal in VVC. In other infections such as trichomoniasis, the pH is raised. Light microscopy of a gram‐stained vaginal smear demonstrates the presence of yeasts in approximately 65–68% of patients with symptomatic VVC [11,12]. A vaginal swab should be sent for fungal culture using Sabouraud’s medium. Figure 10.2 Acute candidiasis with inflammation. There is a wide differential for VVC which includes infective and non‐infective causes. These are listed in Table 10.1. It is also important to remember that candidiasis can coexist with dermatoses, especially psoriasis. Recurrent VVC is defined as four or more episodes of microbiologically proven infection in a year [13]. Many women with other recurrent or persistent vulval conditions such as genital herpes and dermatoses are wrongly diagnosed with recurrent VVC and therefore treated inappropriately. The causes of recurrent VVC are unclear but appear more often to be related to abnormal host factors rather than a particularly virulent or resistant organism [14]
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Vulvovaginal Candidiasis
Epidemiology
Pathophysiology
Clinical features
Diagnosis
Differential diagnosis
Complications
Recurrent vulvovaginal candidiasis
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