Vulvovaginal Candidiasis

J. D. Sobel MD
Basics
Description
Yeast vulvovaginitis usually presents as an acute inflammation of both vagina
and vulva almost always caused by Candida species and rarely by nonCandida organisms
Symptoms and signs vary from mild, moderate, to severe, with infrequent
attacks in some women and recurrent attacks in others (4 attacks/per year).
Alert
Pediatric Considerations
Because Candida species depend on estrogen to alter vaginal epithelium and bacterial
flora, VVC is extremely rare in prepubertal girls. Most episodes of vulvar pruritus and
inflammation in children are NOT due to yeast.
Geriatric Considerations
Attacks of VVC likewise diminish in postmenopausal women not receiving HRT.
Epidemiology
~75% of women will develop at least 1 lifetime episode, 1/2 of whom subsequently
have >1 attack.
Pathophysiology
Microbiology
Any Candida species may cause symptomatic vulvovaginitis, however >90%
due to C. albicans.
Non-albicans species (C. glabrata, C. parapsilosis, C. tropicalis) are less
frequent pathogens and also less virulent, more likely to simply colonize
vaginal secretions and serve as innocent bystanders.
Pathogenesis
Pathogenesis of VVC is complex and multifactorial in etiology.
Risk Factors
Risk factors exist for colonization as well as for transformation from
colonization to frank acute symptomatic vulvovaginitis.
Risk factors for vaginal colonization include:
o

Genetic predisposition (only recently defined)

Behavioral factors (e.g., receptive oral sex, coital frequency, oral

contraceptives)

Biologic factors (e.g., uncontrolled diabetes, pregnancy, antibiotic

administration, HIV infection)

Dermatologic conditions involving vulva (e.g., eczema, psoriasis, atopy, lichen

sclerosus) also predispose to yeast colonization.

Transformation to symptomatic vaginitis may occur for a variety of reasons

but more often than not, no recognizable precipitating factor is evident.
Known precipitating factors include:
o

Antibiotic administration, both systemic and local

Occasionally dietary factors are responsible (e.g., refined sugar excess)

Sexual activity including receptive oral sex

Acute symptomatic VVC most frequently occurs in the week preceding

menses.

The attack rate of symptomatic VVC following antibiotics is 2025%.

Diagnosis
Signs and Symptoms
History
Vulvovaginal pruritus is almost invariably present
Other manifestations of inflammation include:
o

Irritation

Soreness

Burning

Burning on micturition (See Urinary Symptoms: Dysuria.)

Dyspareunia (see topic)

Discharge: A variable white clumpy discharge, but often absent (See

Vaginal Signs and Symptoms: Discharge.)

Physical Exam
Signs include:
o Vulva:

Tests
Lab

Erythema

Edema

Excoriation

Fissure formation

Vagina:

Erythema

Edema

Clumpy white adherent discharge of VVC but also may be

milky.

None of the symptoms and signs is specific and diagnosis cannot be made by
exam alone.

pH: Normal 4.04.5:

o All other forms of infectious vaginitis have pH 4.5

Saline microscopy:

Yeast/Hyphae only found in 50% of women with VVC

No increase in PMNs

Normal flora or rods seen

10% KOH microscopy:

o

Yeast/Hyphae found in 6070% of VVC

Culture (delays diagnosis by 48 hours):

o

Always positive

Nonessential if microscopy positive

Essential for refractory vaginitis/clinically unresponsive to antimycotic

therapy

Essential for recurrent Candida vaginitis

Nonculture confirmation:
o

PCR (now commercially available)

Affirm DNA probe: Excellent, not inexpensive

No better than culture

P.209
Differential Diagnosis
Easy to differentiate from other infectious causes of vaginitis (i.e., bacterial
vaginosis, trichomoniasis, cervicitis), because all have increased pH (>4.5)
Most important alternative diagnosis of normal pH vulvovaginitis is:
o

Contact dermatitis (chemical or hypersensitivity)

In older women atrophic vaginitis always has increased pH (>4.5).

Treatment
General Measures
Decide whether patient has uncomplicated or complicated Candida vaginitis.
Most patients have uncomplicated VVC characterized by mild or moderate
disease caused by C. albicans, with no tendency to a recurrent pattern, are
immunocompetent.
o Uncomplicated VVC requires short-course (including single-dose)
therapy for clinical cure.

In contrast, complicated VVC is characterized by severe disease, non-albicans

Candida, recurrent infection, and immunocompromised host requires more
prolonged therapy for 57 days.

Recurrent VVC (>4 episodes/year):

o

Long-term maintenance regimen: Once weekly fluconazole 150 mg

(long-term cures ~50%)

Medication (Drugs)
Intravaginal agents:
o Butoconazole 2% cream 5 g intravaginally for 3 days*

Butoconazole 2% cream 5 g (Butoconazole1sustained release), single

intravaginal application

Clotrimazole 1% cream 5 g intravaginally for 714 days*

Clotrimazole 100-mg vaginal tablet for 7 days

Clotrimazole 100-mg vaginal tablet, 2 tablets for 3 days

Miconazole 2% cream 5 g intravaginally for 7 days*

Miconazole 100-mg vaginal suppository, 1 suppository for 7 days*

Miconazole 200-mg vaginal suppository, 1 suppository for 3 days*

Miconazole 1,200-mg vaginal suppository, 1 suppository for 1 day*

Nystatin 100,000unit vaginal tablet, 1 tablet for 14 days

Tioconazole 6.5% ointment 5 g intravaginally in a single application*

Terconazole 0.4% cream 5 g intravaginally for 7 days

Terconazole 0.8% cream 5 g intravaginally for 3 days

Terconazole 80-mg vaginal suppository, 1 suppository for 3 days

Oral agent:
o

Fluconazole 150 mg PO tablet, 1 tablet in single dose

Vaginitis due to C. glabrata:

o

High failure rate with azoles including fluconazole

Make sure treatment is indicated and that C. glabrata is not an innocent

bystander.

Trial of boric acid vaginal capsules 600 mg/d (cure rates ~70%)

If symptoms and yeast persist, worth trying 3% amphotericin and 17%

flucytosine cream made up by compounding pharmacy, 5 g daily for 14
days. Cure rates >90%, but expensive

Followup
None required
HIV testing is not required.
Bibliography
Centers for Disease Control and Prevention. Sexually transmitted disease treatment
guidelines 2006. MMWR Morb Mortal Weekly Rep. 2006;(55).
Sobel JD. Vulvovaginal candidosis. Lancet. 2007;369:19611971.
Miscellaneous
Synonym(s)
Candida vaginitis
Fungal vaginitis
Monilial vulvovaginitis
Vaginal candidiasis
Vulvovaginal candidosis
Yeast vaginitis
Yeast vulvitis
Clinical Pearls
Ready access to over-the-counter antifungal agents is associated with wasted financial
expenditures, unfulfilled expectations, and a delay in correct diagnosis.
Abbreviations
HRTHormone replacement therapy
PCRPolymerase chain reaction
PMNPolymorphonuclear leukocytes
VVCVulvovaginal candidiasis
Codes
ICD9-CM
112.1 Candidal vulvovaginitis