Clinical Findings
Signs and Symptoms
Risk factors for Candida infection of the vagina include pregnancy, oral contraceptive use, diabetes mellitus, HIV infection, and antimicrobial therapy, although the majority of infections occur in the absence of these risks. Typical complaints are vulvar pruritus and vaginal discharge (Box 1), although a wide range of symptoms exists. Pruritus, the most common complaint, is often intense, and the discharge, classically described as cottage cheese-like, may range from a thin, white, scant discharge to homogeneously thick. Odor, if present, is mild. Other symptoms may include vulvar burning, external dysuria, vaginal irritation and soreness, and dyspareunia. Symptoms may peak the week prior to menses and wane with the onset of menstrual flow.
Examination may reveal discrete papular or pustular lesions of the vulva, with erythema and swelling of the vulva and labia. The discharge is present within the vaginal vault, and the vaginal mucosa is inflamed and may have adherent white plaques similar to oral thrush. The cervix appears normal.
Laboratory Findings
The vaginal pH is normal (<4.5). Examination of a saline or wet mount preparation of the vaginal discharge may show fungal elements and should not reveal abundant white cells. A KOH preparation is more sensitive in detecting the fungus, as other cellular debris is lysed. Both budding yeast and hyphae are typically present. Culture of the vagina will usually isolate Candida, although this must be interpreted cautiously, as Candida can be part of the vaginal flora without causing disease.
Differential Diagnosis
The signs and symptoms of Candida vulvovaginitis are relatively nonspecific, and therefore the presentation may be confused with bacterial vaginosis, trichomoniasis, and other sexually transmitted diseases. Two or more of these conditions may coexist.
Complications
Some women may develop severe, recurrent infections despite removal of identified risk factors and antifungal therapy. Infection of the vagina is not associated with risk of deep tissue or bloodstream invasion.
Diagnosis
The diagnosis of vulvovaginitis is typically made by history, physical examination, and light microscopy. In women with appropriate symptoms and fungal elements on wet mount or KOH preparation, therapy is indicated without further testing. As up to 50% of symptomatic women with culture-proven infection have negative microscopy, vaginal culture is indicated in those patients with symptoms and no microscopic findings. A vaginal pH >4.5 or a large number of white cells on wet mount should prompt a search for a different or possibly coexistent process.
Treatment
Numerous agents are available for treatment of Candida vulvovaginitis in both topical and oral preparations (Box 5). Among topical agents, cure rates range from 75 to 90%, with the azole preparations (clotrimazole, miconazole, terconazole) having slightly better efficacy than nystatin. The formulation (cream versus suppository versus vaginal tablet) does not alter the success rate; therefore the choice of formulation is a matter of patient preference. Currently there is a trend toward higher doses of topical agents with shorter durations of therapy, with success reported with even high-dose, one-time therapy. Anecdotal failure rates are fairly high with one-dose therapy; thus this is best reserved for women with infrequent infections and mild or moderate symptoms.
Oral azole agents are quite effective for vaginal infection and are more convenient than topical therapy but are more expensive. Fluconazole and itraconazole single-dose therapy are at least as effective as topical therapy.
Cure of Candida vulvovaginitis during pregnancy can be difficult, with relapses frequently occurring. If therapy is extended to 1-2 weeks, topical antifungal therapy is effective. Oral azoles should be avoided during pregnancy.
In women with frequent recurrent infections, therapy is often disappointing, with symptoms recurring within weeks of withdrawal of antifungal agents. In these women, predisposing factors such as diabetes or HIV infection should be considered. HIV testing is appropriate in women with risk factors for HIV infection. If fasting blood glucose values are normal, further testing for diabetes is not required. Oral contraceptives should be discontinued if possible, although continuation of low-dose estrogen preparations, as long as long-term antifungal therapy is used, may be considered. Vaginal douching and treatment of the sexual partner are not recommended. Frequently, no risk factors are identified, and prophylactic therapy is required. The best-studied regimen with proven efficacy for prophylaxis is ketoconazole, 100 mg daily. Toxicity, such as hepatitis, is infrequent but may occur. Other regimens with anecdotal support include fluconazole, 100-200 mg once weekly, and clotrimazole vaginal tablets, 500 mg once weekly.