VULVOVAGINAL CANDIDIASIS VULVOVAGINAL CANDIDIASIS

Differential dx Produced by a ubiquitous, airborne, gram-positive fungus.

Caused by Candida albicans (90%), C. glabrata or C. tropicalis 5-10%
t.vaginalis infection
When the ecosystem of the vagina is disturbed, C. albicans can
bacterial vaginosis
become an opportunistic pathogen.
candida vaginitis

VAGINITIS Factors that enhance growth of fungus:

Vaginal discharge - most common symptom in gynecology 1. Hormonal- pregnancy & menstruation
Other symptoms associated with vaginal infection include 2. Depressed cell-mediated immunity
superficial dyspareunia, dysuria, odor and vulvar burning and 3. Antibiotic use
pruritus
3 common infections of the vagina: It is estimated that three of four women will have at least one
1. Candidiasis (fungal) 25% episode of vulvovaginal candidiasis during their lifetime.
2. Trichomonas (protozoan) 25% The greatest enigma of this condition is the recurrence rate after
3. Bacterial vaginosis 50% an apparent cure, varying from 20% to 80%.
Normal vaginal pH: 3.8-4.5 Approximately 3% to 5% of women experience recurrent
Estrogen → Glycogen content (vaginal epithelial cells) → vulvovaginal candidiasis (RVVC) → four or more documented
Metabolized to lactic acid episodes in 1 year.
The clinical diagnosis of vaginitis depends on the examination
of the vaginal secretions under the microscope and measurement Symptoms:
of the vaginal pH • Pruritus - PREDOMINANT
Normal vaginal secretions: • Vaginal soreness
• White, floccular, or curdy, and odorless • Dyspareunia
• Present only in dependent portions of the vagina • External dysuria
Pathologic discharges: • Abnormal vaginal discharge
 Usually anterior and lateral walls of the vagina Discharge:
 Normal physiologic vaginal discharge consists of cervical White, highly viscous, granular or floccular, odorless
and vaginal epithelial cells, normal bacterial flora, water, Cottage cheese-type, with adherent clumps and plaques
electrolytes, and other chemicals. Vaginal pH <4.5 (in contrast to bacterial and parasitic vaginitis
 Quantitative concentration of bacterial organisms is 10^8 which has elevated pH)
to 10^9 colonies/mL of vaginal fluid. DIAGNOSIS
1. Signs and symptoms of vaginitis
2. Wet smear of vaginal secretion + 10%-20% KOH or
2. Gram stain: yeasts & pseudohyphae
3. Culture: Nickerson or Sabouraud medium
4. Vaginal pH <4.5
5. Whiff test negative

TREATMENT
UNCOMPLICATED VULVOVAGINITIS
Butoconazole 2% cream 5g intravaginally x 3days
Butoconazole 2% cream, 5g single intravag application
Clotrimazole 1% cream 5g intravaginally x 7-14days Metronidazole 500mg PO BID x 7 days OR
Clotrimazole 100mg vaginal tablet x 7days Metronidazole gel, 0.75% one full applicator (5g), intravaginally OD
Clotrimazole 100mg vaginal tablet, 2 tabs x 3days x 5 days OR
Clindamycin cream, 2% one full applicator (5g) intravaginally at HS
• 7days x 7days
• Miconazole 100mg vaginal suppository 1supp x 7days ALTERNATIVE REGIMENS:
• Miconazole 200mg vaginal suppository 1supp x 3days Clindamycin 300mg PO, BID x 7days OR
• Terconazole 0.4% cream 5g intravaginally x 7days Clindamycin ovules 100mg intravaginally once at HS x 3days
• Terconazole 0.8% cream 5g intravaginally x 3days Routine treatment of sex partners not recommended
• Terconazole 80mg vaginal suppository 1supp x 3days All pregnant, symptomatic women require treatment
• Oral agent: Fluconazole 150mg oral tablet 1 tab SD BV associated with adverse pregnancy outcomes
COMPLICATED VULVOVAGINITIS Recommended regimen for pregnant women:
• Topical azoles are recommended for 7 to 14 days Metronidazole 500mg PO, BID x 7days OR
• If using oral therapy, a second dose of fluconazole (150 Metronidazole 250mg PO, TID x 7days OR
mg) given 72 hours after the first dose is recommended. Clindamycin 300mg PO, BID x 7days
RECURRENT VULVOVAGINITIS - (5%)
• ≥ 4 symptomatic episodes of VVC in 1 year TRICHOMONIASIS
The resolution of symptoms typically requires longer duration of Trichomonas vaginalis- anaerobic, flagellated
therapy. Paraurethral glands of males and females
Two-staged treatment: Highly contagious STD
• Initial Intensive Phase: 7-14 days of topical therapy or oral Incubation 4-28 days
fluconazole 3 days apart (e.g., days 1, 4, and 7) Reproductive years
• Maintenance Phase: Oral fluconazole weekly for 6 months or Trichomonas is a hardy organism and will survive for up to 24
topical therapy once weekly for 6 months hours on a wet towel and up to 6 hours on a moist surface.
The primary symptom of Trichomonas vaginal infection is
BACTERIAL VAGINOSIS profuse/copious vaginal discharge.
Most prevalent cause of symptomatic vaginitis  “wet” feeling
Shift in vaginal flora from lactobacilli dominant to mixed flora White, gray, yellow, or green
 "Sexually-associated" infection rather than a true sexually “Frothy” (white bubbles)
transmitted infection. Unpleasant odor (Fishy odor)
Histologically, there is an absence of inflammation in biopsies of Erythema and edema of the vulva and vagina- “Strawberry
the vagina—thus the term vaginosis rather than vaginitis. appearance”.
• Has been associated with upper tract infections, including Vaginal discharge: pH ≥ 4.5
endometritis, pelvic inflammatory disease, postoperative Wet prep
vaginal cuff cellulitis, and multiple complications of NAAT (more sensitive)
infection during pregnancy, such as preterm rupture of TREATMENT
the membranes, endomyometritis, decreased success • Metronidazole 2g PO, single dose OR
with in vitro fertilization, and increased pregnancy loss of • Tinidazole 2g PO, single dose
less than 20 weeks' gestation. • Alternative regimen:
RISK FACTORS  Metronidazole 500mg PO, BID x 7days
New or multiple sex partners • Treatment of partners needed
Women who have sex with women • Avoid intercourse until after both are cured
Douching- monthly or within the prior 7 days • Breastfeeding on metronidazole: Withhold breastfeeding
Social stressors during treatment and for 12-24hrs after the last dose
Lack of lactobacilli
The most frequent symptom is an unpleasant vaginal odor
 musty or fishy odor — often stronger following
intercourse, when the alkaline semen results in a
release of aromatic amines.
Vaginal discharge associated with bacterial vaginosis is thin and
gray-white.
Speculum examination reveals that the discharge is mildly
adherent to the vaginal walls
AMSEL'S CRITERIA
1. Homogenous vaginal discharge
 thin, gray-white, mildly adherent to vaginal wall
2. Vaginal discharge: pH ≥ 4.5
3. Aminelike odor when mixed with potassium hydroxide- “Whiff
test”
4. Wet smear: CLUE CELLS >20% of the number of the vaginal
epithelial cells.
TREATMENT