Candidiasis - Vulvovaginal Infections

CANDIDIASIS

Vulvovaginal candidiasis is a fungal or yeast infection caused by strains of Candida (Table 47-1). Candida albicans accounts for most cases, but other strains, such as Candida glabrata, may also be implicated. Many women with a healthy vaginal ecosystem harbor Candida but are asymptomatic. Certain conditions favor the change from an asymptomatic state to colonization with symptoms. For example, use of antibiotics decreases bacteria, thereby altering the natural protective organisms usually present in the vagina. Clinical infection may occur during pregnancy, with a systemic condition such as diabetes mellitus or human immunodeficiency virus (HIV) infection, or in a patient taking corticosteroids or oral contraceptives.

Clinical Manifestations

Clinical manifestations include a vaginal discharge that causes pruritus (itching) and subsequent irritation. The discharge may be watery or thick but has a white, cottage cheese-like appearance. Symptoms are usually more severe just before menstruation and are usually less responsive to treatment during pregnancy. Diag-nosis is made by microscopic identification of spores and hyphae on a glass slide prepared from a discharge specimen mixed with potassium hydroxide. With candidiasis, the pH is 4.5 or less.

Medical Management

The goal of management is to eliminate symptoms. Treatments include antifungal agents such as miconazole (Monistat), nystatin (Mycostatin), clotrimazole (Gyne-Lotrimin), and terconazole (Terazol) cream. These agents are inserted into the vagina with an applicator at bedtime and may be applied to the vulvar area for pruritus. There are 1-night, 3-night, or 7-night treatment courses available. Oral medication is also available (fluconazole [Diflu-can]). Fluconazole is given in a one-pill dose; relief should be noted within 3 days.

Vaginal creams are available without a prescription; however, patients are cautioned to use these creams only if they are certain that they have a yeast or monilial infection. Many patients use these remedies for problems other than yeast infections. If the pa-tient is uncertain about the cause of her symptoms or has not ob-tained relief after using these creams, she is instructed to seek health care promptly. Yeast infections can sometimes become re-current and may be related to cell-mediated immunity or to an allergic response. Women with recurrent yeast infections benefit from a comprehensive gynecologic workup.