Vulvovaginal Candidiasis Flashcards
What is vaginitis
Inflammation of the vaginal tissue that may be accompanied by itching, burning, irritation, pain, odor and vaginal discharge
One of the most common reasons women seek medical care
What are non-infectious causes of vaginitis
Causing vulvovaginal pruritus without discharge (itching)
Causing vaginal discharge primarily (no/less itch)
what are the causes of vulvovaginal pruritus
• Poor hygiene • Irritant or allergic dermatitis • Skin disorders: – Psoriasis – Lichen planus – Lichen sclerosus – Squamous cell hyperplasia
what are the causes of vaginal discharge (without itch)
- Desquamative inflammatory vaginitis
- Atrophic vaginitis
- Foreign bodies
- Excessive physiologic secretions (stress, pregnant, ovulation)
- Certain cancers
what are infectious causes of vaginitis
Bacterial Vaginosis (BV) - most common
Vulvovaginal Candidiasis (VVC) - yeast infection
Trichomoniasis
Other (chlamydia, gonorrhoea, etc)
Which type of vaginitis:
- little itching
- homogenous, white-grey discharge, malodorous “foul fishy”
- ph >4.5 (5-6)
bacterial vaginosis
Which type of vaginitis:
- some itching
- frothy, yellow-green discharge, malodorous
- dysuria
- strawberry cervix
- ph >4.5 (6)
Trichomoniasis
Which type of vaginitis:
- LOTS of itching
- cottage cheese discharge, no odour
- dysuria and dyspareunia
- redness and/or swelling
- pH <4.5 (normal pH)
VVC
What organism causes bacterial vaginosis
Gardnerella vaginalis
Mycoplasma hominis +
What organism causes trichomoniasis
Trichomonas vaginalis
What organism causes VVC
Candida albicans
Which type of vaginitis is sexually transmitted
trichomoniasis
not an STI in bacterial vaginosis but rates > in sexually active women
What are risk factors for bacterial vaginosis
IUD use Vaginal Douching Absence of or decrease in lactobacilli New/multiple sexual partners smoking
Risk factors for trichomoniasis
History of STIs Lack of condom use Multiple sex partners Lower socioeconomic status smoking
Risk factors for VVC
Race (more likely for african americans) Vaginal Douching Meds: ABX, CST increased Estrogen Levels Uncontrolled DM Immunodeficiency
Treatment for bacterial vaginosis
Preferred treatment:
• Metronidazole 500mg BID x 7 days
- Metronidazole 0.75% gel: 5g intravaginally once a day x 5 days
- Clindamycin 2% cream: 5g intravaginally once a day x 7 days
Partner management for bacterial vaginosis
treatment of partner not warranted
Treatment of trichomoniasis
- Metronidazole 500mg BID x 7 days (can be used if no swab test is done bc will treat BV or trichomoniasis)
- Metronidazole 2g single dose
Partner management for trichomoniasis
Treat partner
Avoid sex
- dont treat/defer asymptomatic pregnant patients
Partner management for VVC?
Typically NO need to treat sexual partner (unless uncircumcised)
Exception: C. balanitis, RVVC
Avoid sex until therapy complete
How does VVC occur?
- candida is a normal part of the vagina flora
- symptomatic candidiasis is caused by overgrowth (usually due to changes in host environment)
- disruption of vaginal ecology can occur with diabetes, pregnancy, or HIV disease. In some women, disruption can occur with the use of antibiotics and douching
What are the 2 classes of VVC
Uncomplicated (can be treated by RPh) and complicated (refer)
What is uncomplicated VVC
- Sporadic, Infrequent VVC
- Mild-to-moderate signs and symptoms
- Likely caused by C. albicans
- Non-immunocompromised host
What is complicated VVC
- Recurrent VVC (RVVC)
- Severe symptoms
- Non-albicans species
- Compromised host
Red flags of VVC
- Is pregnant
- Is premenarchal
- Presents w/ vaginal symptoms for the 1st time
- Presents w/ concurrent symptoms of fever or pelvic pain
- Presents w/ signs or symptoms inconsistent with VVC
- Coloured or malodorous discharge
- Is predisposed to VVC: DM, HIV
- Is taking predisposing medications
- Has a recurrence of VVC (>3/year or 2 within past 2 months)
What are the criteria for self treating VVC?
- vaginal symptoms infrequent
- > 1 previous diagnosed episode
- current symptoms are mild-moderate and consistent with VVC
- vaginal pH <4.5 (if measured)
What is vagisense
- tells you if pH >4.5 (turns blue)
- detects BV or trichomoniasis infections
- do not use around menses (pH naturally elevated)
When to avoid using vagisense
- In pregnancy
- <1 day before or the day after your period
- there are signs of menstruation or any vaginal bleeding
- <12 hours after sexual intercourse or vaginal douching
- <72 hours after the 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
Vaginitis prevention: Hygiene measures
- Keep genital area CLEAN and DRY; wipe from front to back.
- Avoid OTC feminine hygiene products & douches.
- Change sanitary pads & tampons regularly; Practice safe sex
Vaginitis prevention: Clothing measures
- Choose COTTON underwear (avoid synthetic, silk, or nylon)
- Avoid tight or restrictive synthetic clothing; avoid thongs
- Promptly change out of wet clothes/swimsuits
Vaginitis prevention: diet measures
- Balanced, nutritious diet
- Decrease sucrose and refined carbs if poorly controlled diabetic
- Drink sufficient fluids
- Eat yogurt (8 oz/day) with live lactobacillus cultures
How to treat uncomplicated VVC
Non pharm therapy +
nonRX (Vaginal Imidazole Antifungals or Oral Triazole Antifungal: Fluconazole)
or RX (Vaginal Triazole Antifungal: Terconazole)
Nonpharm therapy
Sodium bicarbonate sitz bath
– Add 1 teaspoon sodium bicarbonate to 1 pint of water
– Add 2-4 tablespoons of the solution to 2 inches of bath water
– Sit in the sitz bath or bathtub for 15 minutes as needed for symptom control
Consume yogurt?
What are OTC Vaginal Imidazoles available
- clotrimazole (canestan)
- 1/3/6 days
- miconazole (monistat)
- 1/3/7 days
- CI: warfarin
strength increases as days decrease
What type of product is recommended for bedtime
Creams
What type of product is recommended for anytime of day
ovule
What OTC oral triazoles are available?
Fluconazole (CanesOral, DiflucanONE, Monicure)
150 mg PO x 1 dose
- do not use if pregnant or trying
What RX vaginal triazole is available?
Terconazole (terazol 7, taro-terconazole)
Vaginal Cream 0.4%: 1 applicatorful intravaginally qhs x 7 days
Do multi-day treatments work the same as single-dose?
- equal efficacy
- faster rates of symptom relief
What to do if nonRx therapy is ineffective?
refer
what should sexual partner do in RVVC cases?
- use antifungal cream x 7 days while woman is receiving treatment
How long should symptoms improve by
within 2-3 days, resolve within 7
refer if >7 days
When to follow up?
3 days
What treatments are recommended for pregnancy
- longer duration is better
- clotrimazole 1% cream 5 g intravaginally per day x 7–14 days
- clotrimazole 100 mg vaginal tablet once daily x 7 days
- miconazole 2% cream 5 g intravaginally per day x 7 days
- miconazole 100 mg vaginal suppository once daily x 7 days
- terconazole 0.4% cream 5 g intravaginally x 7 days
What to avoid using when pregnant
fluconazole
boric acid
What is the best treatment option for breastfeeding women
Any topical Clotrimazole or Miconazole formulation
Others:
- nystatin does not enter breastmilk
- fluconazole is excreted in milk but compatible
Products to avoid
- Vaginal Douches
- Vaginal Anti-Itch Creams
- Natural Health Products (need antifungal)
- Personal/Genital Hygiene products
