vulvovaginal candidiasis Flashcards
what is vaginitis
Inflammation of the vaginal tissue that may be accompanied by itching, burning, irritation, pain, odor and vaginal discharge
what are non infectious causs of vaginitis
- causing vulvuvaginal pruritus wihtout discharge
- poor hygiene
- irritatnt. allergic dermatitis
- skin disorders; PsoriasiS, Lichenplanus, Lichensclerosus,Squamous cell hyperplasia
- causing vaginal discharge primarily
- Desquamative inflammatory vaginitis
- atrophic vaginitis (vag dryness, body will try to inc discharge
- foreign bodies
- excessive physiologic secretions
- certain cancers
infectious causes of vaginitis
- bacterial aginosis (#1)
- vulvovaginal cadidiasis (VVC)
- trichomiasis
- other
describe symptom presentation, vaginal discharnge, cinlical findgins and vaginal pH of
bacterial vaginosis
- Symptom presentation
- vulvar pruritus + discharge
- 50% asymptomatic
- vaginal discahrge
- homogeneous adherent, thin, milky white-grey, fishy smell
- clinical findings
- little or no inflamation
- pH
- >4.5
describe symptom presentation, vaginal discharnge, cinlical findgins and vaginal pH of
trichomoniasis
- symptoms
- vulvar pruritus (SUPER ITCHY)
- disrcahge
- dysuria
- 64-90% asymptomatic
- vaginal discahge
- frothy off white yello green
- malodorous
- clinical finsings
- cervical petechiae “strawberry cervix” -> dots on it
- pH
- >4.5
describe symptom presentation, vaginal discharnge, cinlical findgins and vaginal pH of Vulvovaginal candidiasis
- symptoms
- vulvar pruritis (itchiest one!)
- discharge, dysuria, hysparenuia (painful sex)
- <20% asymptomatic
- vaginal discharge
- thick, clumpy white, “cottage cheese”
- no odour
- Clinical findinds
- erythema +/- edema of vulva and vegina
- vaginal pH
- <4.5 NOT CHANGED FROM NORMAL
causatic organism, transmission, risk factors and potential complications of
bacterial vaginosis
- causative organism
- gardnerella vaginalis, mycoplasma hominis (+)
- transmission
- not at STI
- rates inc in secually active women
- Risk factors
- IUD, vaginal douching, absense of or dec in lactobacilli
- mew/multiple sexual partners
- smoking
- Potential compications
- pre term labour/delivery
- premature rupture of membranes, PID, spontaneous abortion
causatic organism, transmission, risk factors and potential complications of
trichomoniasis
- causative organism
- trichomonas vaginalis
- transmission
- sexual
- risk factors
- history of STIs, lack of condom use, multiple sex partners
- lower socioeconomic status, smoking
- potential complications
- pre term rupture of membranes & delivery
- inc risk of HIV acquisition
causatic organism, transmission, risk factors and potential complications of
vulvovaginal candidiasis
- causative organism
- candidia albicans
- transmission
- not suually acquired sexually
- Risk factors
- race
- vaginal douching
- meds: ABX, CST, inc estogen levels
- uncontolled DM
- immunodeficiency
- Potential complications
- resistance, recurrent VVC
- inc risk of other ifnections: vaginitis and penile candidiasis
treatment for bacterial vaaginosis
- metronidazole 500mg BID f7d
- metronidazole 0.75% gel: 5g intravaginally 1d f5d
clindamycin 2% cream: 5g intravaginally 1d f7d
*routine treatment of sexual partner not warranted
treatment for trichomoniasis
- mtrionzadole 500mg BID f7d (acts for both trichomoniasis and bacterial vag)
- metronidazole 2g single dose
*treat sexual partner -> avoid sex until therapy is compelte
*dont treat asymtpomatic pregnant patients
treatment for vulvovaginal cadidiasis
- antifungals
*typically no need to treat sexual partner -> exception is C. balanitis, RVVC
*avoid sex until therapy is compelte
pathogenesis of VVC
- Candida special are normal in skin and vaginal, not sonciered sexually transmited
- symptomatic candidasis caused by overgorwth of C. albicans and other candidia species
- distruption of normal vaginal exolocy & host immunity -> diabetes, pegnnacy or HIV
- can also occur bc of antibiotics and douching
main symptoms of VVC
- thick white cottage cheese discharge with NO odor
- noraml vaginal pH
- vulvar pruritis
- vulvar erythema
- +/1 vulvar edma
classifications of VVC
- uncomplicated
- sporadic, infrequent VVC
- mild to moderate signs and symptoms
- likely caused by C. albicans
- non- immunocompromised host
- Complicated
- recurrent VVC
- severe symptoms
- non albicans species
- compromised host
red falgs for VVC
- pregnant
- premenarchal
- presents w/ vaginal symptoms for 1st time (MUST have had it before to self treat)
- presents w/ concurrent symptoms of fever or pelvic pain
- present w/ signs or symptoms inconsistent with VVC (coloured or malodorous discharge)
- predisposed to VVC: DM, HIV
- taking predisposing medications (Chemo)
- has recurrence of VVC (> 3.year or two within past 2 months)
when can you self treat VVC
- Vaginal symtpoms inrequent (3 less/year)
- one previously diagnoses VVC
- symptoms are mild -> consistent with VVC
- pH < 4.5 (if measured)
*must satifsy all
what can be used to chekc vaginal pH
- vagisense
- just tells you if pH is above 4.5
- if yellow pH is not above 4.5, any blue is positive
*can get a postive test but still have a yeast infection -> can get mixed infections)
- if used corretnyl and you tested negative, dont have baterial vaginosis
when should you avoid Vagisense usage to test pH
- if pregnant (REFER)
- < 1 day before or the day after your period
- signs of menstruation or any vaginal bleeding
- <12 hours after sexual intercourse or vaginal douching
< 72 hours after application of vaginal preparations
goals of therapy for VVC
Rapidly relieve signs & symptoms
Eradicate causative organism
Prevent recurrence & complications-> Reestablishment of normal vaginal flora
Prevent misdiagnosis and delayed treatment of another condition
Reduce inappropriate use of anti- fungals
*single course of therapy is effective in achieving tis, if they have symptoms after need to refer
how to prevent aginitis
- Hygiene
- keep genital area clean and dry -> wipe fron to back
- avoid OTC feminine hygiene products and douches
- charge sanitary pads and tampons reguarly -> practie safe sex
- Clothing
- choose cotton underwear (avoid synthetic, silk or nylon)
- avoid tight or restictive clothing -> avoid thongs
- promptly change out of wet clothes/swimsuits
- Diet
- balanced nutritous diet
- dec sucrose and refined cards if poorly controled diabetc
- drink sufficient fluids
- eat yogurt (8 oz/day) with live lactobacillus cultures?
- balanced nutritous diet
first lien options to treat VVC
- non pharmacologic therapy PLUS
- non rx therapy or rx therapy
- non rx
- vaginal imidazole antifugals
- oral triazole antifunal: fluconazole
- RX
- vaginal triazole antifuncal: terconazole
- non rx
what is second line treatment for VVC
- polyene antifungal: nystatin
*2nf line bs longer duration for use and adverse effects
do case and questions at end
non pharm therapy for VVC
- temporary symptomatic treatment of irritated vulva -> sodium bicarbonate sitx bath
- add 1 tsp of sodium bicarbonate to 1 pint of water
add 2-4 tbsp of solution to 2 inces of bath water
- sit in it for 15 min as needed for symptoms control
vaginal imidazoles for treatment of VVC
*first line
- otc options:
- Clotrimazole (canesten): 1,3 and 6 day products (1 day has lots of side effects)
- miconazole (monistat): 1,2, and 7 day products
- interacts with warfarin!
- ADR
- well tolerated
- if v hgih dose get local burning, ittitarion and itching
forms of products of VVC
cream and ovules
- cream use HS -> maximized contract time
ovule can be used any time of day
*comfort tab is an ovule
treatment of VVC with fluconazole
ex: canesORAL, diflucanONE, monicure
- dose: 150mg PO i dose
adr: headache, GI efects, rish, inc LFT
- CIs/precautiosn: hypersensitivity, renal/liver disease, pregnancy
*fluconazoel in high dose linked to brith defects in 1st trimester -> avoid if trying to precome preg or preg
triazoles for treatment of VVC
terconazole
- dose: vaginal cream 0.4%: 1 application intravaginally qhs f7d
- ADRs: headache, vaginal discomfort
*RX therapy
when would you use just oral therapy vs combo for oral and cream
- if super itchy do the combo bc get quicker relief
- oral takes a day to treat itch
sex during vaginal antifungal treatment
- refrain
- vaginal lubricatns and spermicides should NOT be used concurrently
- do not use latex condoms & diaphragms during therapy for 3 days agter (has mineral oil that makes cnodoms less effective)
monitoring VVC
- symptoms should improve in 2-3 days of initiation of therapy & resolve in 7 days
*refer is > 7 days
- educate patient: resolution time, adverse effects of treatment
*if presistent symptoms or new onset uncharacteristic of VVC REFER
- follow up phone call after 3 days to dicuss: treatment effectiveness and importance of adherence
DO PRACTICE QUESTIONS AND CASE STUDY
how to treat VVC in pregnanct comen
- **Clotrimazole
- 1% cream, 100mg vaginal tab 1d f7d or 100mg tab 2d f3d, 500 mg vag tab in single app
- **miconazole
- 2% vaginal cream 5g intravag f7d
- 100 mg vag sup 1d f7d, 200 mg vag sup 1d f3d
- Nystatin
- 100,000 unit vag tab 1d f14d (less effective than topical axoles)
- Terconazole
- 0.4% cream: 5f intravag f7d *
- 0.8% cream 5g intravag f3d
- 80mg vag sup daily f3d
* = preferred treatment
what VVC meds should be avoided in pregnant women
– fluconazole
boric acid
treatment of VVC when breastfeeding
- topical azole = best option: any tpoical clotrimazole or miconazole
- nystatin: does not enter breast milk
fluconaozle: excreted in milk but AAP compatible
products to avoid when have VVC
VaginalDouches
• VaginalAnti-ItchCreams
- NaturalHealthProducts
- Personal/GenitalHygieneproducts
patient counseling: how to aply vaginal cream
- insert the antifungal at bedtime to minimize leakage from the vagina
- Significant symptom relief expected within 24-48 hours
- Continue therapy for the recommended length of time, even if symptom-free or menstruating
- Do not use tampons or douche while using a vaginal antifungal product & for 3 days after
- Refrain from sexual intercourse for 1week
– Do not use latex condoms & diaphragms
