Treatment of Vaginal Fungal Infection

W. Steven Pray, Ph.D., R.Ph., Professor of Nonprescription Products and Devices, School of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK

US Pharmacist. 2001;26(9) 

In This Article

Introduction

Vaginitis with vaginal discharge is a common problem, causing 10 million women each year to visit a physician's office for care.[1] The three most common causes of vaginitis are bacterial, trichomonal, and fungal. In as many as 75% of females with vaginitis, vulvovaginal candidiasis is the cause.[2] Since nonprescription antifungals first became available over a decade ago, numerous female patients have sought advice from a pharmacist about self-care. The number may well dwarf those who have made physician appointments.

Bacterial vaginitis may be caused by a host of organisms, including Gardnerella vaginalis (the most common), Mobiluncus species, Mycoplasma hominis, Prevotella, Bacteroides, and Peptostreptococcus.[1] Three points help confirm bacteria as the source of vaginitis: (1) The discharge is thin, homogeneous, white, and resembles skim milk adhering to vaginal walls; (2) The pH is above 4.5 (normal vaginal pH is 3.8-4.4); (3) When a sample of the discharge is mixed with 10% KOH, it will produce a typical "fish-like" odor (this is indicative of an increase in anaerobic activity, which yields amines such as cadaverine and putrescine).

Trichomonal vaginitis causes a frothy, copious discharge that is yellowish or greenish and may have a fishy odor.[1] The vaginal pH exceeds 5-6. While many patients are asymptomatic, others report vaginal and vulvar discomfort, soreness, burning, and dyspareunia (pain during sexual intercourse). Patients who report manifestations of these symptoms must be referred to a physician for prescription medications.

As many as 15%-20% of females with vaginal yeast infections are asymptomatic.[3] The reported symptoms of vaginal candidal infection are fairly characteristic and duplicative upon recurrence. They include vulvar and/or vaginal pruritus (which may be intense), burning soreness (especially when urinating), irritation, dyspareunia, and the well-known curd-like discharge that adheres to the vaginal walls.[4] Several noninfectious etiologies can produce similar symptoms, as illustrated in Table 1. In order to confirm Candida as the cause, the physician should test vaginal pH, and should treat a vaginal specimen with 10% KOH.[5] The alkaline pH of KOH does not affect the chitinous components of the fungi, whereas all nonchitinous elements in the specimen (white blood cells, bacteria, epithelial cells) are dissolved. Microscopy reveals the characteristic architecture of fungal organisms (yeast buds and hyphae). Another clue is the presence of a rash with a prominent border, similar to that seen in candidally infected diaper rash. The rash may spread outward from the vulvar area to involve the groin. The patient may also have satellite lesions outside the visible border.[6] In worse cases, the patient may also experience excoriations, formation of pustules, and fissures of the labia.[5]

Candida albicans is able to adhere to vaginal epithelium more readily than other Candida species, which is probably why it causes about 80% of yeast infections. Other, less common, causes are C. glabrata, C. parapsilosis, C. guilliermondii, and C. tropicalis.[6] These latter organisms may not respond as readily to nonprescription therapy. Unfortunately, there is no reliable clinical method of differentiating the various Candida organisms.[6] It may be that treatment failures point to the presence of a non-albicans infection. Researchers hypothesize that the widespread home use of nonprescription antifungal medications has caused the emergence of more resistant strains, and that the number of chronic and recurrent cases will eventually increase as a result.[4]

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