Vaginal thrush Flashcards
What is the technical term for vaginal thrush?
Vulvovaginal candidiasis
What is vulvovaginal candidiasis?
Symptomatic inflammation of vagina and/or vulva caused by a superficial fungal infection
What is the causative organism in most cases of vulvovaginal thrush?
Candida yeast
What are the 2 classes of vulvovaginal candidiasis?
- Uncomplicated: sporadic or infrequent, mild to moderate, likely due to Candida albicans, not assoc with pregnancy or poorly controlled diabetes
- Complicated: recurrent, severe, infection with other yeasts, pregnancy, infection in diabetic or immunocompromised
What are 4 things that make an episode of vulvovaginal candidiasis uncomplicated?
- Sporadic or infrequent
- Mild to moderate
- Likely due to candida albicans
- Not associated with risk fators e.g. pregnancy or poorly controlled diabetes
What are 5 factors that make vulvovaginal candidiasis ‘complicated’?
- Recurrent: 4 or more episodes in 1 year, with at least partial resolution between episodes
- Severe
- Yeasts other than candida albicans
- Pregnancy
- Immunocompromised or diabetic
What are 5 possible symptoms of vulvovaginal candidiasis?
- Vulval itching
- Vulval soreness and irritation
- Vaginal discharge - usually white, cheese-like, non-offensive
- Superficial dyspareunia
- Dysuria
What are 3 possible signs of vulvovaginal candidiasis?
- Vulvovaginal inflammation and erythema
- Vaginal fissuring (splitting or tearing of vulvar skin)
- Excoriation of vulva
When is microscopy and fungal culture of vaginal secretions recommended in thrush? 3 instances
- For supporting the diagnosis,
- and in cases of severe or recurrent vulvovaginal candidiasis,
- or treatment failure
What are 6 groups that vulvovaginal candidiasis can be divided up into for the treatment?
- Uncomplicated infection
- Severe infection
- Recurrent infection
- Uncontrolled diabetes or immunocompromised patient
- Pregnant
- 12-15 years old
What are 4 situations when specialist advice should be sought or urgent referral arranged for vulvovaginal candidiasis?
- Diagnosis is unclear
- Symptoms do not improve following treatment
- Non-albicans Candida species infection is present
- Systemic symptoms occur
What are 9 differentials for vaginal thrush?
- Bacterial vaginosis
- Trichomoniasis
- Chlamydia
- Gonorrhoea
- Genital herpes
- Vulval eczema, psoriass
- Lichen simplex or sclerosus
- Atrophic vaginitis - postmenopausal
- Malignancy of vulva, vagina, cervix, uterine lining
What are 4 general self care pieces of advice to give to patients with vulvovaginal candidiasis?
- Avoid predisposing factors: washing and cleaning area with soap or shower gels, cleaning area more than once a day, washing underwear in biological washing powder and using fabric conditioners, vaginal douching, wearing tight fitting and/or non-absorbent clothing
- Wash vulval area wih soap substitute external, no more than once a day
- Use simple emollient to moisturise area
- Consider probiotics (such as live yoghurts) orally or topically
What is the management of uncomplicated vulvovaginal candidiasis?
- Prescribe intravaginal antifungal cream or pessary (clotrimazole, miconazole) OR oral antifungal (fluconazole or itraconazole)
- Topical imidazole in addition, if vulval symptoms: clotrimazole 1% or 2% cream, 2-3 times a day
What is the best approach for vulvovaginal candidiasis treatment for breastfeeding women?
Prescribe an initial course of intravaginal clotrimazole or miconazole, or oral fluconazole
Topical imidazole if vulval symptoms
(i.e. same as normal)
What safety netting advice should you give a woman receiving treatment for vulvovaginal candidiasis?
If symptoms have not resolved within 7-14 days, return to GP
What are the doses and regimens for intravaginal pessaries to treat uncomplicated thrush? 2 examples
- clotrimazole 200mg pessaries x3 over 3 nights, or 500mg single dose pesary, 1 night dose
- miconazole 1.2g single-dose vaginal capsules
What are the doses and regimes for oral treatment of uncomplicated vulvovaginal candidiasis?
- fluconazole: 150mg single dose
- itraconazole: 200mg bd for 1 day
What are the 2 options for vulvovaginal candidiasis intravaginal creams?
- Clotrimazole 10% cream: insert 5g into vagina as single dose at night
- Fenticonazole 2% cream: insert 5g into vagina in morning and evening for 3 days
What are 8 things to do in the case of treatment failure of uncomplicated vulvovaginal candidiasis?
- Confirm initial treatment was used as recommended
- Reassess for risk factors and remove/control
- Consider alternative diagnoses
- Send vaginal specimen for mciroscopy, culture and sensitivity if appropriate
- Consider measuring vaginal pH to assess likelihood of candida (<4.5) bacterial vaginosis (>4.5) or Trichomonas vaginalis (>4.5)
- Treat infection - consider changing to different formulation if poor compliance, consider extended course
- Reinforce self management advice
- Refer or seek specialist advice if aged 12-15, doubt about diagnosis, treatment failure unexplained, non-albicans identified, treatment fails again
What are the 2 options for extended courses of intra-vaginal antifungal cream in treatment failure of uncomplicated vulvovaginal candidiasis?
- Miconazole 2% cream - 5g into vagina once daily for 10-14 days, or 5g into vagina twice daily for 7 days
- Econazole 1% cream - 5g into vagina and apply to vulva at night for at least 14 nights
What are the 3 options for extended courses of intra-vaginal pessaries in treatment failure of uncomplicated vulvovaginal candidiasis?
- Clotrimazole 100mg pessaries - 1 each night for 12 nights
- Clotrimazole 200mg pessaries - 1 into vagina once at night for 6 nights
- Econazole nitrate 150mg pessaries - 1 into vagina once at night for 6 nights
What are the 2 options for extended courses of oral antifungals in treatment failure of uncomplicated vulvovaginal candidiasis?
- Fluconazole 100mg od 7 days
- Itraconazole 200mg od 7 days
What are 6 aspects of management of severe vulvovaginal candidiasis?
- Send vaginal specimen for microscopy, culture and sensitivity
- Prescribe antifungal: 2 doses oral fluconazole 150mg to be taken 3 days apart. if CI, 2 doses of clotrimazole pessaries 500mg, 3 days apart
- Topical imidazole if vulval symptoms. e.g. clotrimazole 1% or 2%
- advise to return if symptoms have not resolved within 7-14 days
- follow up and test of cure not necessary if symptoms resolve
- do not routinely treat asymptomatic sexual partner
