Vaginal Candidiasis

Question 1

Symptoms of Vaginal Candidiasis

Answer 1

vulval or vaginal itch and irritation
 a non-offensive vaginal discharge
superficial dyspareunia, and dysuria
Vulval soreness
Discharge occurs in only 20% of patient
if discharge present has little or no odor and it is described as resembling cottage cheese or its is curd-like
Symptoms are generally acute in onset

Question 2

Conditions to eliminate

Answer 2

Vaginal vaginosis- most likely cause of vaginal discharge
Thrush/candidiasis- likely cause
Trichomoniasis, atrophic vaginitis, cystitis, chlamydia, cysytitis, chlamydia- Very unlikely

Question 3

Specific question to ask the patient

Answer 3

Discharge- any discharge with a strong odor should be referred- Trichomoniasis and vaginosis are associated with fishy odor

colour of discharge- grey white(vaginosis)
greenish-yellow(trichomoniasis)
clear dischargeand odourless(thrush)

age - Thrush can occur in any age group
Bacterial vaginosis and trichomoniasis- rare in
premenarchal girls
Trichomoniasis rare in women greater than 60years

pruritus- Vaginal itching tends to be more prominent in thrush , itch slight or absence in BV or T

onset- Sudden onset in thrush whereas in VG or T, onset tends to be less sudden

dhx- 
pmh-
tried otc-
duration of symptoms-
Are you diabetic?
oral contraceptives?
Corticosteriods
Chemical irritants? can alter vaginal ph

Question 4

When to refer

Answer 4

Discharge that has a strong smell
women <16 and > 60years- thrush unusual in this age group
Patients with diabetes- might suggest poor diabetic control
OTC medication failure- could suggest misdiagnosis or an underlying problem
patient predisposed to thrush
recurrent attack

Question 5

Predisposing factors to Vaginal Thrush/ Candidasis

Answer 5

Predisposing Factors

There are a number of factors that may predispose a patient to a Candida infection, these should be considered when counseling your patient. Predisposing factors include:

·Previous treatment with a broad-spectrum antibiotic. Due to the removal of normal flora by the action of broad-spectrum antibiotics, any Candida present with that area of the body will replicate and cause infection.

· Immunocompromised patients are susceptible to all types of infection and Candida is no exception. It is important to remember that patients may be immunocompromised due to a current disease or due to the treatments they are taking.

· Candida infections can also be a sign of controlled diabetes. Higher sugar levels in bodily fluids will encourage the replication of bacteria and yeasts (they will use the sugars as an energy source) putting the patien

Question 6

Treatment of Vaginal Thrush

Answer 6

Factors Influencing Treatment Options

When advising patients on the treatment of vaginal candidiasis, the following may be considered:

· For most women

· An initial course of an intravaginal antifungal cream or pessary (clotrimazole, econazole, miconazole, or fenticonazole) would be suitable.

· An oral antifungal (fluconazole or itraconazole) may be considered after discussions with the patient.

· For women aged 60 years and older

· Oral antifungals may be more acceptable than intravaginal antifungals because of the ease of administration.

· For girls aged 12–15 years

· Topical clotrimazole 1% or 2% applied 2–3 times a day is considered suitable, or seek specialist advice. Do not prescribe an intravaginal or oral antifungal.

· For breastfeeding women

· initial course of intravaginal clotrimazole or miconazole would be a suitable treatment option if the patient agrees.

· Oral fluconazole (only if an intravaginal antifungal is unacceptable to the woman and the patient has been counselled).

·

· If the patient is also experiencing vulval symptoms, use a topical imidazole in addition to an oral or intravaginal antifungal.

· Clotrimazole 1% or 2% cream applied 2–3 times a day.

· Ketoconazole 2% cream applied 1–2 times a day (for adults aged 18 years and older)