Candidal Vaginitis: Symptoms, Causes and Treatment

Vaginal candidiasis (candidal vaginitis or thrush) is an inflammation of the vaginal mucosa that is usually caused by Candida albicans, but can also be triggered by other Candida species or yeast. It is estimated that 75% of women experience at least one episode of candidal vaginitis, and 40%-45% have two or more episodes. Approximately 10%-20% of women experience complicated candidal vaginitis, which requires special diagnostic and therapeutic efforts.

Clinical picture

The patient presents with itching, pain, vaginal mucosal swelling and hyperemia, and thick and copious vaginal discharge. Vulvar edema, fissures, excoriations and dysuria may be present. Based on clinical manifestations, microbiologic examination, the patient’s health status, and response to therapy, candidal vaginitis can be classified as uncomplicated and complicated.

Clinical criteria for uncomplicated candidal vaginitis:

• A sporadic or infrequent episode;
• Moderate degree of manifestation;
• The most likely cause is Candida albicans;
• Women without immunosuppression.

Clinical criteria for complicated candidal vaginitis:

• Recurrent episodes of candidiasis;
• Severe manifestations of the disease;
• It’s not caused by Candida albicans;
• Women with diabetes mellitus, immunodeficiency conditions (e.g., HIV infection), concomitant immunodeficiency, or immunosuppressive therapy (e.g., corticosteroids).

Recurrent candidal vaginitis is diagnosed when there are three or more episodes of symptomatic candidal vaginitis per year. Recurrent candidal vaginitis can be either idiopathic or secondary (associated with frequent use of antibiotics, diabetes, etc.). The pathogenesis of recurrence is poorly understood, and most women have no obvious predisposing or underlying disease. C. glabrata and other non-albicans Candida species are found in 10-20% of women with recurrent candidal vaginitis.

Diagnosis of vaginal candidiasis

The diagnosis can be made in a woman who has signs and symptoms of vaginitis and microscopic examination of vaginal discharge demonstrates budding, hyphae, or pseudohyphae. Candida glabrata does not form pseudohyphae or hyphae, making it difficult to diagnose. Candida vaginitis does not cause changes in vaginal pH (it remains <4.5). Using a 10% KOH solution on wet preparations improves visualization of yeast and mycelium by disrupting cellular material that may hide yeast or pseudohyphae. For those with negative microscopy results but signs or symptoms, seeding of secretions for vaginal Candida cultures should be considered. If bacteriologic seeding is not possible, empiric treatment may be considered. Identification of Candida culture in the absence of symptoms is not an indication for treatment, as Candida and other yeasts make up the vaginal microbiome in approximately 10-20% of women.

Differential diagnosis

Investigation with appropriate testing is important to identify other causes of vaginal symptoms, including sexually transmitted infections, vulvar, vaginal and cervical malignancies, pelvic inflammatory disease, vulvo-vaginal herpes, vaginal fistulas, trauma and vulvovaginal dermatoses.

Treatment of vaginal candidiasis

Short-term topical preparations (i.e., single dose and treatment regimens for 1-3 days) effectively treat uncomplicated candidal vaginitis. Azole treatment results in symptom relief in 80-90% of patients completing therapy.

Drugs for the treatment of vaginal candidiasis

Treatment of vaginitis associated with non-albicans Candida spp.

The optimal treatment for these types of vaginitis remains unknown, but a longer duration of therapy (7-14 days) with a fluconazole and azole regimen (oral or topical) is recommended. Administration of 600 mg of boric acid in a gelatin capsule vaginally is indicated for relapse. This therapy regimen leads to eradication in 70% of cases.

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Treatment of recurrent vulvovaginal candidiasis

Most episodes of recurrent candidal vaginitis caused by C. albicans respond well to short-term oral or topical azole therapy. However, a longer duration of initial therapy – 7-14 days of topical therapy or an oral dose of fluconazole (100 mg, 150 mg, or 200 mg) – is recommended to maintain clinical control. To maintain remission, oral fluconazole (100 mg, 150 mg, or 200 mg dose) is taken weekly for 6 months. If this regimen is not possible, an alternative in the form of intermittent topical treatment may also be considered.

Treatment in pregnancy

In pregnant women, only topical azole therapy applied for 7 days is recommended.