Vulvovaginal candidiasis: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:30

Vulvovaginal candidiasis, or VVC, is the second most common form of vaginitis, after bacterial vaginosis. It is the result of inflammation of the vagina and vulva due to infection with yeast, most commonly by Candida albicans.
Now, asymptomatic colonization of the vagina with Candida species is common. However, when these species overgrow and invade the epithelial cells of the vagina, inflammation occurs.

Focused H&P0:30–2:26

Your first step in evaluating a patient who presents with a chief concern suggesting vulvovaginal candidiasis is a focused history and physical exam.
Patients typically report an abnormal vaginal discharge, as well as vaginal itching. They may also describe vulvar symptoms, such as itching, pain, redness or swelling.
Other symptoms might include dysuria; or dyspareunia, which is pain during sex. When taking history, be sure to ask about any risk factors.
First up, there’s the recent use of medications like broad spectrum antibiotics, which can alter the vaginal flora and allow Candida to overgrow.
Next, ask if they have recently treated their symptoms with over the counter medications. Many patients successfully treat VVC with over the counter antifungals.
However, when patients present with incomplete or partial treatment, it can be more difficult to make a clinical diagnosis.
Finally, the medical history should also include questions about underlying medical risk factors for VVC, such as a history of diabetes or immunosuppression, which may include conditions like HIV, or patients on systemic corticosteroids.
Here is a clinical pearl! VVC is uncommon, before puberty, and in postmenopausal patients who are not using hormone replacement therapy, because Candida species are unlikely to proliferate in the vagina in the absence of estrogen.Now for a focused physical exam.
You’ll notice that the vaginal discharge is often thick, white and curd-like. The vulva may appear erythematous with edema and excoriations from scratching, and may develop fissures.
Based on these findings, you should suspect VVC.The next logical step is to confirm your diagnosis.To do this, obtain samples of the discharge from the vaginal walls and fornices.

Diagnosis2:26–5:13

Assess the discharge first by smearing it on a slide and applying a drop of 10% potassium hydroxide, or KOH, to the preparation.
KOH breaks down epithelial cells and white blood cells in the specimen, but does not affect pseudohyphae and spores, which allows for better microscopic visualization of yeast.
In addition to microscopy, you should also assess the vaginal pH, and consider sending swabs of the discharge for vaginal culture.
You could also consider testing for Candida through polymerase chain reaction, or PCR; or by using a molecular test.Here is another clinical pearl!
The choice of diagnostic testing can vary based on cost and availability. Microscopy is inexpensive, easy to use, and provides rapid results, so it remains the most recommended test, but ​​at times may have large interobserver variability.
Second line to microscopy are PCR tests; they're more accurate than microscopy. New DNA-based molecular tests may provide species information with reproducible accuracy; but they are the most expensive and are often unavailable in low resource settings.
Lastly, vaginal cultures are rarely performed, since they’re also expensive and take more time, but are useful if microscopy is unavailable or Candida typing and antifungal susceptibility is desired.Now let’s review our test results.
If KOH microscopy is negative for pseudohyphae and spores, and the vaginal pH is greater than 4.5; or if the vaginal culture, PCR, or molecular testing is negative, consider an alternative diagnosis.
On the other hand, if KOH microscopy reveals pseudohyphae and spores, as well as many lactobacilli; while the vaginal pH is 3.5 to 4.5; or if vaginal culture, PCR, or molecular testing is positive, you have a diagnosis of vulvovaginal candidiasis.
Once you have made the diagnosis of VVC, let’s see if it’s an uncomplicated or a complicated case. It is important to assess for complicated disease.
This takes in account the number of episodes, symptoms and any comorbidities the patient might have, leading to immunocompromise.
This includes patients with diabetes mellitus, HIV infection, or those using medications that suppress the immune system, such as systemic corticosteroids.
First let’s consider uncomplicated VVC. If the patient had fewer than three episodes of vulvovaginal candidiasis in one year; the symptoms are mild to moderate; and they are not immunocompromised; they are diagnosed with uncomplicated vulvovaginal candidiasis.
When it comes to treatment, antifungal preparations are effective for uncomplicated VVC. Therefore, you can prescribe a vaginal azole, like miconazole or clotrimazole, or an oral azole, like fluconazole.

Uncomplicated VVC5:13–6:46

Vaginal azole therapy comes in 1, 3, and 7 day preparations, all with varying potency of medication. When you counsel patients on choosing their treatment option, be sure to mention that 1 day preparations may have worse side effects due to the higher potency of medication and consider that 3 or 7 day courses might be better tolerated.
In addition, be sure to advise all patients that some vaginal preparations may weaken the latex in condoms or diaphragms.
When offering advice, be sure to tell them about hygiene and behavioral measures that may reduce the risk of VVC, such as avoiding douching and scented hygiene products, as well as quickly changing out of wet clothing such as bathing suits or gym clothes.
Keep in mind that sexual partners won’t need to be treated, since VVC is not a sexually transmitted infection.Now, let’s move on to complicated vulvovaginal candidiasis.
If the patient has one of the following: more than 3 distinct episodes of VVC in one year; severe symptoms with findings such as extensive vulvar erythema, edema, excoriations and fissures; or being immunocompromised; they are diagnosed with complicated vulvovaginal candidiasis.
The first step in the management of complicated VVC is to obtain a vaginal yeast culture to determine the Candida species.
This can identify non-albicans Candida, such as Candida glabrata, and also allows for susceptibility testing. Non-albicans Candida is naturally resistant to azole therapy, but keep in mind that there has been increasing azole resistance among albicans species.If a non-albicans Candida species is identified, you have a few options.

Complicated VVC6:46–9:42

Start by giving an oral or vaginal azole for 7 to 14 days, but don’t use fluconazole as it will be ineffective. If this doesn’t work, try vaginal boric acid capsules for 3 weeks.
As before, advise patients to avoid douching and scented hygiene products, and to quickly change out of wet clothing like bathing suits or gym clothes.
If symptoms continue despite following these indications, consider consultation with an infectious disease or vulvar dermatology specialist, who might consider the use of newer, yet more expensive, non-azole antifungal agents.
Alright, let’s talk about different findings on the vaginal yeast culture. If the culture identified Candida albicans, that means that the patient has a recurrent infection.
In this case, initiate a prolonged treatment regimen such as 7-14 days of vaginal azole therapy, like clotrimazole, or up to 3 doses of oral fluconazole.
After this initial treatment, consider suppressive therapy with weekly oral or vaginal azoles for up to 6 months. Patients who have diabetes or are immunosuppressed generally respond well to these longer regimens, but be sure to also optimize the management of any underlying medical conditions.
Finally, advise patients on hygiene and behavioral measures that may reduce the risk of VVC like avoiding douching and scented hygiene products, as well as avoiding wearing wet bathing suits and gym clothes.Now one last clinical pearl!
If the patient is pregnant, they can safely use vaginal azoles, but you should avoid using oral fluconazole, particularly in the first trimester, as it has been associated with spontaneous abortion and congenital anomalies in those taking higher doses.Alright, as a quick recap… Vulvovaginal candidiasis is commonly diagnosed with KOH microscopy and assessing vaginal pH, but vaginal cultures and PCR or molecular tests can be performed as well.
Uncomplicated VVC can be treated with short regimens of vaginal or oral antifungals, usually azoles. For complicated cases, you need to get a vaginal yeast culture to determine the Candida species that’s causing the infection.
If the infection is caused by non-albicans Candida species, treat them with a non-fluconazole oral or vaginal azole, and consider vaginal boric acid if needed.
On the other hand, if the infection is caused by Candida albicans, initiate prolonged treatment regimen or suppressive therapy.

Review9:42–10:42

Be sure to treat any underlying medical conditions as well. Finally, all patients with VVC should be advised to avoid certain hygiene practices like douching, avoid scented hygiene products, and quickly change out of wet clothing like bathing suits or gym clothes.
yeast culture to determine the Candida species that's causing the infection If the infection is caused by non albans Candida species treat them with a non fluconazole oral or vaginal azo and consider vaginal boric acid if needed On the other hand if the infection is caused by candida albicans initiate prolonged treatment regimen or suppressive therapy be sure to treat any underlying medical conditions as well Finally all patients with VV C should be advised to avoid certain hygiene practices like douching avoiding scented hygiene products and to quickly change out of