Candida vulvovaginitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Candida vulvovagintis is an infection of the vagina and the vestibulum, common in women in the reproductive age group. It is caused by various Candida species with Candida albicans most common pathogen followed by other species like Candida glabarta, Candida krusei etc. Patients present with vulvar pruritus, burning micturition and vaginal discharge.The diagnosis of candidal infection requires a collaboration of clinical and diagnostic findings. Patients have typical white cottage chesee like discharge with hyphae and spores demonstrated on microscopy. Patients with uncomplicated infection respond well to topical and oral azole therapy. 5 to 8% of women develop recurrent vaginitis, which is defined as more than 4 episodes in a year. These patients require a longer duration of therapy with an induction and maintenance phase.

In 1839, B. Lagenbeck from Germany described a yeast-like fungus for the first time in the human oral infection thrush and its ability to cause it.

Candida vulvovaginitis can be classified based on the duration, as well as the strain of Candida causing the infection.

Several virulence factors of Candida are implicated in vulvovaginitis, but the process of transition from asymptomatic vaginal colonization to symptomatic vulvovaginitis is poorly understood. There may be genetic factors associated with Candida vulvovaginitis, as infection runs in families in many cases and is more common in African-American women.

Candida yeasts are usually present in most people, but uncontrolled multiplication resulting in disease symptoms is kept in check by other naturally occurring microorganisms, e.g., bacteria co-existing with the yeasts in the same locations, and by the human immune system.

In a study of 1009 women in New Zealand, the fungus, Candida albicans, was isolated from the vaginas of 19% of apparently healthy women. Carriers experienced few or no symptoms. However, external use of irritants (such as some detergents or douches) or internal disturbances (hormonal or physiological) can perturb the normal flora, constituting lactic acid bacteria, such as lactobacilli, and an overgrowth of yeast can result in noticeable symptoms. Pregnancy, the use of oral contraceptives, engaging in vaginal sex immediately and without cleansing after anal sex, and using lubricants containing glycerin have been found to be causally related to yeast infections. Diabetes mellitus and the use of antibiotics are also linked to an increased incidence of yeast infections. Candidiasis can be sexually transmitted from men to women, but not from a woman to a man. Diet has been found to be the cause in some animals. Hormone Replacement Therapy and infertility treatments may also be predisposing factors.

Candida Vulvovaginitis must be differentiated from diseases with similar presentation such as bacterial vaginosis, trichomonas vaginitis and atrophic vaginitis.

Candida vulvovaginitis is not a reportable disease and epidemiological studies on the prevalence of the disease are hard to perform.

Antibiotics used to treat other types of infections change the normal balance between organisms in the vagina by decreasing the number of protective bacteria. Being pregnant, having diabetes, or being obese all create conditions that help yeast grow more easily.

There are no screening recommendations for candida vulvovaginitis.

Candida vulvovaginitis is a self limiting disease with no complications, but few patients develop recurrence. Candida vulvovaginitis is very responsive to local or oral antifungals.

Pruritus is the most significant symptom and candida infection is characterized by a thick, white “cottage cheese-like” vaginal discharge

Physical examination of of the genitalia will demonstrate edema and erythema of the vulva and labia with fissures and excoriations of the external genitalia.Thick whitish vaginal discharge adherent to the vaginal walls may be present.

A small amount of the vaginal discharge is examined using a microscope (called a wet mount and KOH test). Sometimes, a culture is taken when the infection does not improve with treatment or recurs many times.

Antifungal agents are indicated in candidiasis. Commonly used drugs include Amphotericin, Clotrimazole, Nystatin, Fluconazole and Ketoconazole.

There is no role for surgery in the treatment of Candida vulvovaginitis. Medical therapy with topical and/or oral anti-fungal drugs is the mainstay of treatment.

There are no means to prevent Candida vulvovaginitis, but wearing a cotton underwear may help reduce the risk of infection.

Prevention of recurrent vulvovaginal candidiasis, maintenance fluconazole prophylaxis may be used.^[1] Treatment of a male sexual partner with oral ketoconazole does not seem to influence the cure or recurrence rates in women with Candida vulvovaginitis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

In 1839, B. Lagenbeck from Germany described a yeast-like fungus for the first time in the human oral infection thrush and its ability to cause it.

• In 1839, B. Lagenbeck from Germany described a yeast-like fungus for the first time in the human oral infection thrush and its ability to cause it.^[1]
• In 1923 the Candida albicans was described by Christine Marie Berkhout. Over the years the classification of the genera and species has evolved. Obsolete names for this genus include Mycotorula and Torulopsis. The species has also been known in the past as Monilia albicans and Oidium albicans. The current classification is nomen conservandum, which means the name is authorized for use by the International Botanical Congress (IBC).
• The full current taxonomic classification is available at Candida albicans.
• The genus Candida includes about 150 different species. However, only a few of those are known to cause human infections. c. albicans is the most significant pathogenic (disease-causing) species. Other Candida species causing diseases in humans include c. tropicalis, c. glabrata, c. krusei, c. parapsilosis, c. dubliniensis, and c. lusitaniae.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Candida vulvovaginitis can be classified based on the duration, as well as the strain of Candida causing the infection.

Candida vulvovaginitis can be classified based on the duration of the infection and based on the strain of Candida causing the infection.

Candida vulvovaginitis can be divided based on the duration and number of episodes of the infection into:^[1][2][3][4]

• Acute, uncomplicated: these are usually sporadic cases of Candida vulvovaginitis, which respond to topical antifungal therapy and have a high cure rate.
• Acute, complicated: symptoms are more severe than uncomplicated infections and typically require a combination of oral and topical anti-fungal treatment.
• Recurrent Vulvovaginal Candidiasis (RVVC): defined as 4 or more episodes of Candida vulvovaginitis per year, usually caused by the same strain of Candida. Treatment also requires a combination of oral and topical antifungal agents.
• According to 2015, Treatment of STD guidelines – Candida vulvovaginitis can be classified into uncomplicated and complicated based on the following features:^[5]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Several virulence factors of Candida are implicated in vulvovaginitis, but the process of transition from asymptomatic vaginal colonization to symptomatic vulvovaginitis is poorly understood. There may be genetic factors associated with Candida vulvovaginitis, as infection runs in families in many cases and is more common in African-American women.

• C. albicans exists as blastospores, germ tubes, pseudomycelia, true mycelia and chlamydospores on special culture media. C. glabrata exists exclusively in blastospores.
• All strains of Candida species possess a yeast surface mannoprotein which helps in adhering to epithelial cells of the vagina.^[10][11]
• Germination of the spores helps in colonizing the vagina.^[12]
• Proteolytic enzymes, toxins and phospholipase destroy the proteins that normally impair fungal invasion, enhancing the ability of Candida to colonize the vagina.^{[10][11][13][14]}
• Phenotypic switching of Candida is described in patients with recurrent vaginitis.^[15]
• C. albicans can form biofilms on the intrauterine devices or sponges, causing disease recurrence.^[16]

• Candida vulvovaginitis is a microbial disease and not all patients with detectable pathogen are symptomatic. Multiple risk factors and the imbalance in the protective vaginal defenses predispose patients to develop active disease.
• Candida vaginal infections are more common in the reproductive age group because of the high concentration of estrogen as it increases the amount of glycogen in the vagina providing a carbon source for Candida organisms to colonize. It also increases the adherence of Candida to the vaginal epithelial cells.^[17]
• The most common source of the infection is from the perianal area. Other less common source is sexual transmission and persistence of organisms in the vagina after treatment which is responsible for recurrence.^[18]
• The initial step of infection is colonization and symptoms appear with the invasion of the blastospores or pseudohyphae of the vaginal wall.^[19]
• The understanding of the transition from asymptomatic vaginal colonization with Candida to symptomatic vulvovaginitis is not clear.^[11][13]

• Few genetic factors are thought to be involved in patients with recurrent Candida vulvovaginitis.^[20]
• Supporting evidence is that Candida vaginitis is common in African-American women, runs in families and its association in patients with ABO-Lewis non-secretor phenotype (a rare blood group).
• In addition, women with recurrent Candida vulvovaginitis were found to have decreased concentrations of mannose binding lectin (MBL), hence, the variant (MBL) gene is thought to be a contributing factor in the development of Candida vulvovaginitis.^[10][21][2]

On speculum examination typical curdy white discharge is present.

• 
  This photograph is a speculum examination of the vagina with Candida infection and the typical thick, curdy vaginal discharge. – By Mikael Häggström – Own work, CC0, https://commons.wikimedia.org/w/index.php?curid=35323300
• 
  This autopsy photograph of the kidneys demonstrates the multifocal punctate lesions visible on the serosal surface (arrows). Don’t confuse these small yellow punctate lesions with the fat that is adherent to the renal capsule. – © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved
• 
  This photograph of the cut surface of these kidneys shows that these multifocal punctate lesions are primarily in the cortex (arrows). – © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved

Microscopic examination of the wet mount with 10% KOH or saline demonstrates hyphae, pseudohyphae and blastospores.

• 
  This is a a microscopic image of Candida albicans, grown on cornmeal agar medium. – By Y tambe – Y tambe’s file, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=233284
• 
  This is a low-power photomicrograph of lymph node with three prominent areas of Candida colonies (arrows). Even at this low magnification, the purple-staining yeast and pseudohyphae can be easily seen. This section was stained with Periodic Acid-Schiff Hematoxylin (PASH), which stains the cell wall of fungi to make them more easily visible. – © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved
• 
  This is a low-power photomicrograph of one of the Candida colonies from this lymph node. The chains of yeast which are termed “pseudohyphae” are apparent at this magnification. – © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved
• 
  This higher-power photomicrograph shows the yeasts and pseudohyphae in this focus of Candida organisms. – © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved
• 
  This high-power photomicrograph shows the yeasts (1) and pseudohyphae (2). – © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved

• Candida vulvovaginitis may be associated with other pathogens that cause vulvovaginitis. These include Trichomonas vaginalis and Gardnerella vaginalis. The association may be a mixed infection, where 2 or more pathogens are symptomatic, or a co-infection, in which there are 2 or more pathogens but some are not symptomatic.^[22][23]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Candida vulvovaginitis is caused by many different species of Candida. They are divided into Candida albicans and Candida non-albicans species based on the causative pathogen.

• Candida albicans: These strains are isolated in 85 to 95% patients with yeast infection.^[1]
• Candida non albicans: Candida glabrata is the most common isolated pathogen in this group affecting 10 to 20% of women and is associated with recurrent Candida vulvovaginitis.^[2]

These are less commonly isolated in patients but is important to identify the species as they are less sensitive to standard azole therapy and cause recurrent infection.^[3][4]

• Candida parapsilosis^[5]
• Candida tropicalis
• Candida krusei^[6]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Candida Vulvovaginitis must be differentiated from diseases with similar presentation such as bacterial vaginosis, trichomonas vaginitis and atrophic vaginitis.

Candida Vulvovaginitis must be differentiated from the following diseases which have a similar presentation:^{[1][2][3][4][5]}

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Candida vulvovaginitis is not a reportable disease and epidemiological studies on the prevalence of the disease are hard to perform.

• Epidemiological studies on Candida vulvovaginitis are hard to perform, because of several factors:^[1][2]
  • Candida vulvovaginitis is not a reportable disease.
  • The diagnosis of Candida vulvovaginitis is based on clinical presentation and positive laboratory findings. Relying on a positive culture alone would likely overestimate the prevalence of Candida vulvovaginitis.
  • The use of over-the-counter (OTC) topical anti-fungals makes it difficult to conduct epidemiological studies.
• Candida is the second most common cause of vaginal infection in young women following bacterial Vaginosis.^[3]

• Incidence of Candida vulvovaginitis is higher in pregnant women.^[4][5]
• Women in reproductive age group are prone for Candida vulvovaginits and at least one episode is reported in 70 to 75% in this population group.^[6]
• 40 to 50% of patients with a prior yeast infection have multiple episodes of yeast infection.^[4]
• Among the adult population 5 to 8% women have more than four episodes of infection.^[7]
• In 20% asymptomatic healthy adolescent women, Candida species can be isolated from the vagina.^[8]

Candida vulvovaginitis is more prevalent among African American women than white American women.^[7]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Some of the risk factors associated with the development of Candida vulvovaginitis include diabetes mellitus, immunosuppression and recent antibiotic use.

The following risk factors have been implicated in predisposing patients to Candida vulvovaginitis:

• Previous infection with Candida vulvovaginitis^[1]
• Previous infection with neisseria gonorrhea^[2]
• Nulliparity^[3]
• Luteal phase of the menstrual cycle ^[3]
• Recent antibiotic use^[4]
• Pregnancy^[3]
• Diabetes mellitus^[5][6]
• Obesity
• Immunosuppression, such as HIV or glucocorticoid use^[7]
• Condom use^[8]

Table adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71^[11]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2], Aravind Kuchkuntla, M.B.B.S[3]

Candida vulvovaginitis is a self limiting disease with no complications. Candida vulvovaginitis is very responsive to local or oral antifungals.

Candida vulvovaginitis is a common infection of women in reproductive age group. Patients present with vulvar pruritus, dysuria, and vaginal discharge. Half of the affected patients have multiple episodes of the infection and less than 10% have recurrent infection.^[1]

Candida albicans vulvovaginitis has excellent prognosis with azole therapy. Patients with non-Candida albicans infections are prone to have recurrence and treatment with boric acid and oral fluconazole has good prognosis.^[2]

Candida vulvovaginitis is a self limiting disease with no complications.

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