Candida vulvovaginitis overview

# Overview
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.

# Historical Perspective
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.

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

# Pathophysiology
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.

# Causes
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.

# Differentiating candida vulvovaginitis from other Diseases
Candida Vulvovaginitis must be differentiated from diseases with similar presentation such as bacterial vaginosis, trichomonas vaginitis and atrophic vaginitis.

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

# Risk Factors
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.

# Screening
There are no screening recommendations for candida vulvovaginitis.

# Natural History, Complications and Prognosis
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.

# Diagnosis

## History and Symptoms
Pruritus is the most significant symptom and candida infection is characterized by a thick, white "cottage cheese-like" vaginal discharge

## Physical Examination
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.

## Laboratory Findings
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.

# Treatment

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

## Surgery
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.

# Prevention

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

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