Vulvitis: Factors of Development, Clinical Manifestations, Diagnosis, Treatment
Vulvitis - inflammation of the vulva, manifested by lesions of the labia, clitoris, pubis and vaginal vestibule. Clinical manifestations, diagnosis and treatment.
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
| The drug | Form of release | Dosage | Method of application |
|---|---|---|---|
| Clotrimazole | 1% cream | 5 g | Intravaginally |
| Clotrimazole | 2% cream | 5 g | Intravaginally |
| Miconazole | 2% cream | 5 g | Intravaginally |
| Miconazole | 4% cream | 5 g | Intravaginally |
| Miconazole | Vaginal suppository | 100 mg | Intravaginally |
| Miconazole | Vaginal suppository | 200 mg | Intravaginally |
| Miconazole | Vaginal suppository | 1200 mg | Intravaginally |
| Thioconazole | 6.5% ointment | 5 g | Intravaginally |
| Butoconazole | 2% cream (bioadhesive) | 5 g | Intravaginally |
| Terconazole | 0.4% cream | 5 g | Intravaginally |
| Terconazole | 0.8% cream | 5 g | Intravaginally |
| Terconazole | Vaginal suppository | 80 mg | Intravaginally |
| Fluconazole | Pills | 150 mg | Orally |
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.
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.
FAQ
1. What is thrush and how does it manifest itself?
Vaginal candidiasis is a fungal lesion of the vaginal mucosa caused by yeast-like fungi of the genus Candida. Characteristic manifestations of the disease are intense itching in the genital area, burning when urinating, redness and swelling of the mucous membranes, as well as the appearance of abundant curd-like discharge of white color.
2. What are the main causes of thrush?
The occurrence of candidal vaginitis is associated with the active reproduction of opportunistic fungi Candida, which is promoted by various factors. These include decreased immunity, prolonged use of antibiotics, hormonal changes during pregnancy or when using oral contraceptives, the presence of diabetes mellitus, wearing synthetic underwear, and the use of scented hygiene products.
3. How to distinguish thrush from other gynecologic diseases?
Differential diagnosis is based on characteristic clinical manifestations and laboratory tests. Unlike bacterial vaginosis, candidiasis does not have a sharp unpleasant odor of discharge, and the pH of the vagina remains within normal limits (acidic environment). A gynecologic examination and microscopic examination of the smear are required to make an accurate diagnosis.
4. What are the most effective treatments?
In uncomplicated forms of the disease, topical antifungal drugs in the form of vaginal suppositories or creams containing clotrimazole, miconazole or nystatin are used. As systemic therapy, a single intake of fluconazole in a dosage of 150 mg can be prescribed. Recurrent and complicated forms require a longer course of treatment and maintenance therapy.
5. What is the danger of thrush during pregnancy?
Candidiasis in pregnancy requires mandatory treatment, as it can lead to infection of the fetus during labor. Pregnant women are prescribed only topical forms of antifungal drugs, as systemic agents can have a negative impact on fetal development.
6. Is thrush a sexually transmitted disease?
Although candidal vaginitis is not a classic STI, it is possible to transmit the fungal infection through sexual contact. The sexual partner only needs to be treated if he or she develops clinical symptoms of the disease.
List of Sources
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