Etiology, Diagnosis, and Management of Vaginitis

Jane Mashburn, CNM, MN, FACNM

Disclosures

J Midwifery Womens Health. 2006;51(6):423-430. 

In This Article

Vulvovaginal Candidiasis

VC is the most common cause of infectious vaginitis, accounting for between 40% and 50% of all cases. It may cause genital discomfort, loss of productivity, reduced sexual pleasure, psychological problems, and medical expenses.[36] Seventy-five percent of reproductive-age women will have at least one episode of VC in their lifetime, and 40% to 45% will have two or more episodes.[1,38]

Candidal infection is most often caused by Candida albicans, a fungal organism that is a part of the normal flora of the vagina of reproductive-age woman, but causes >90% of cases of symptomatic vaginitis. However, infection can also be caused by other species, such as C glabrata and C tropicalis. The latter two types often are more resistant to treatment.[25] The relationship between colonization of the vagina (growth of C albicans on vaginal culture) and vaginitis symptoms is not understood. Certain factors are predictive of yeast colonization: positive HIV status, having diabetes, recent IV drug use, and recent antibiotic use.[1,37] It is thought that other host factors play a role in whether or not women are symptomatic because a large number of women who are colonized have no symptoms.[37] VC is classified as uncomplicated or complicated based on frequency, symptoms, microbiology, and response to treatment ( Table 3 ).

Vulvar irritation, including itching and discomfort of the vulvar skin and vaginal epithelium, vaginal discharge, dyspareunia, and discomfort with voiding are the most common symptoms reported.[1,25,38] The subjective diagnosis of Candida infection may be inaccurate and, in fact, the accuracy of self diagnosis has not been validated.[1,2,37] Ferris et al.[2] evaluated women within 24 hours of buying over-the-counter antifungal medications. Only participants who presented with unopened over-the-counter antifungal products were entered into the study. Pelvic examinations were performed, including cultures and wet mounts for microscopy. Only 33.7% of the participants actually had VC; 13.7% had normal vaginal findings.

The diagnosis of VC is suggested in the woman who presents with vulvar irritation with itching, erythema, and a normal pH. Spores, hyphae, or yeast buds identified on wet mount confirm the diagnosis. The addition of potassium hydroxide to the wet mount slide will remove debris that may obscure the hyphae, and assists in making an accurate diagnosis. Women may have mixed infections; white blood cells and clue cells may also be present.[4] Yeast culture is another diagnostic test for yeast. However, finding a positive culture for yeast in a symptom-free woman does not warrant treatment, as 10% to 20% of women carry yeast normally.[25]

Uncomplicated VC is easily treated with topical azole antifungal medications in single or short-term doses[25,38] ( Table 4 ). This class of drugs is usually more effective than the older nystatin class of drugs. Treatment with the prescribed therapy of azole drugs results in relief of symptoms in 80% to 90% of patients.[25] Many of these azole drugs are available over-the-counter, but should be used by women who had a previous confirmed diagnosis of VC and currently have the same symptoms. Women should be reminded that many of these topical agents are oil-based and can therefore weaken condoms and diaphragms. It is recommended either that another form of contraception be used or that they abstain from sexual intercourse during the course of treatment.

Persistence of symptoms after treatment with the over-the-counter medication or recurrence of symptoms within 2 months of treatment warrants a visit to the clinician for an accurate diagnosis and treatment regimen.[25] Women who have self-diagnosed may have done so incorrectly.[2]

Treatment of partners is not recommended in women with uncomplicated VC as it is not acquired sexually. Treatment of uncomplicated VC in women who are HIV-positive is the same as that for women who are HIV-negative.[25]

Complicated VC occurs in 10% to 20% of women and is much more difficult to treat. Recurrent VC, defined as 4 or more cases per year, is one type of complicated VC.[25] Most of these cases are caused by C albicans. These infections respond well to the typical azole medications but require a longer period of therapy. Initial therapy may be either a topical azole for 7 to 14 days, or an oral dose of fluconazole 150 mg followed by repeating the same dose 3 days and 6 days after the initial treatment.[4,25] The first line maintenance regimen is oral fluconazole (100 mg, 150 mg, or 200 mg dose) weekly for 6 months. Others include topical clotrimazole 200 mg twice a week, clotrimazole 500 mg vaginal suppositories once weekly, or other topical treatments used intermittently.[25]

The most beneficial duration of suppression in not known.[3,25] Approximately 90% of women will be without symptoms during 6 months of suppressive therapy and about half will have no recurrences for another 6 months after stopping therapy.[4] Routine treatment of male partners is controversial.[25]

Ten percent of VC infection is caused by organisms other than C albicans. Of these cases, about 50% will respond to the standard azole treatment. The other 50% are much harder to treat, and the optimal treatment is not known.[29,38] In cases that do not respond to the regular azole therapy, identification by culture of the specific organism is recommended.[1,4,25,37] For the noncandida cases, the CDC first recommends longer therapy for 7 to 14 days with any nonfluconazole drug. If this is not successful, 600 mg of boric acid in a gelatin capsule may be administered vaginally once daily for 14 days.[25] This product may be found in health food stores.

Lactobacilli, normally-occurring bacteria in the mouth, intestinal tract, and vagina, have been suggested as treatment for recurrent VC. Although these bacteria are known to have some antimicrobial function, which would inhibit growth of harmful bacteria, studies have not supported that the use of oral or vaginal forms of lactobacillus prevent VC.[1,39,40] Hilton et al.[41] completed a small study to determine if eating yogurt containing lactobacillus acidophilus decreased the incidence of Candida cases. The incidence was reduced by 85% during the months the women consumed a yogurt-containing diet as compared to those who consumed a yogurt-free diet. More long-term studies are needed to evaluate these methods of treatment.[41,42]

Many cases of VC occur during pregnancy and, in fact, pregnancy is listed as a cause of complicated VC[25,38] ( Table 3 ). Although rare, VC can lead to neonatal Candida infection, which is a major cause of septicemia in neonates. The neonatal infection is associated with a high morbidity rate (25%) and high mortality rate (25%-54%).[43] Because VC in pregnancy is considered to be "complicated," the recommended treatment is topical azole treatment for 7 days. Oral antifungals are category C drugs, and are not recommended during pregnancy.

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