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Vulvovaginal candidiasis (VVC)
Louise Oliver
GP Extension Registrar GU Medicine
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Size of the problem
55% of women by mid !s "ave "ad##$ Geiger M& 'oxman (& Gilles)ie (*+ AmJ Pub Hlth ,--5.85/,,012,,03+
U) to 4 of all women at least , lifetimee)isode
53+0 million )er year ,-+3 inmedication costs 'oxman (& et al STDs 2 !!!.27/6!265+
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Consequences
7ot directly life t"reatening but8++ Poor self esteem+ Psyc"osexual )roblems+9tewart :E& *"elan $;& et al
Obstetrics & Gynecology ,--!.76 /352351+ ;rving G et al+ STIs. 74!"#$$4%'
()) Oct. --,!-6 9ocially unacce)table to discuss Often misunderstood
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Causative agent
$+ albicans 352-!%
$+ glabrata 52,!%
Ot"ers/ $+tro)icalis& $+=rusei& $+ =efyr&> 9acc"aromyces cerevesiae ?(rewer@syeastA
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Symptoms
#ulval itc"ing or soreness
#aginal disc"arge
9u)erficial dys)arenuia
External dysuria
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Signs
Eryt"ema
'issuring
7on offensive disc"arge
9atellite lesions
Oedema
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Investigations
GUM setting/
Gram stain or saline microsco)y of
anterior fornix or lateral vaginal walldisc"arge
$ulture
GP setting/
$"arcoal swab for culture
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Classification of VVC9obel B: et al& Am J Obs Gynecol ,--3.178/!62,,+
, $andida colonisation Uncom)licated ##$
6 $om)licated ##$
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1 Candida colonisation
$andida is an o))ortunist )at"ogen 7ormal vaginal flora in many women
C% in longitudinal studyPriestley $B etGenitourin *e+ ,--C.73/623+
Dig"er in )regnancy ?6!20!%A
Positive D#9 for $andida doesn@tdistinguis" between commensal and)at"ogen
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2 ncomplicated VVC
mild
infreuent
non2)ersistent
non2)regnant women
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! Complicated VVC
severe& )ersistent& recurrent ##$ orunderlying "ost abnormality
:ivided into/ , severe vulvovaginal candidiasis
)ersistent non2 albicans infection
6 recurrent vaginal candidiasis
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"reatment
7ational guidelines www+mssvd+org+u= General advice Fo)ical > oral aole t"era)y 3!2-5%
cure rate ?non2)regnant womenA Oral aole t"era)y avoid in )regnancy
> breast feeding :o not treat asym)tomatic $andida
colonisation
http://www.mssvd.org.uk/http://www.mssvd.org.uk/
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"opical therapy( given #V)
$lotrimaole 5!!mg stat< !!mg x 6
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$ral therapy
'luconaole ,5!mg PO stat
;traconaole !!mg PO (: , day
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Choice of therapy
Oral H more acce)table to some
H Iuic=er onset H systemic side effects
H Inot safe in )regnancy
#aginal H messy
H occasional irritation
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Se%ual partner
Grade evidence to s"ow treatment ofasymptomatic male sexual partners
is not required
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&ollo' up
Unnecessary if sym)toms resolve
Fest of cure unnecessary
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Symptoms fail to settle
9evere ##$ 2 re)eat fluconaole,5!mgs after 6 days 9obel B: et al Am J Obs Gyn,e !!,.185/616261-+
I 7on albicans infection
I Recurrent ##$
I ;rritation secondary to to)ical t"era)y I *rong diagnosis
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ifferential diagnosis
Fric"omonas vaginalis
(acterial vaginosis
Der)es sim)lex virus
#ulval disease
$"lamydia
Gonorr"oea
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12 'omen referred 'ith *problem
thrush+ to r avid ,hite at -a'thorn
-ouse. -eartlands -ospital
:7 re2attend
0!%
R##$,-%
Ecema
,%
Ot"er
,3%
#estibulitis
0%
7il of note
6%
7on albicans
0%
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/ 0ecurrent VVC
Researc" area 9)eciated fungal culture
II'($ and random glucose IID;# test only mandatory if ot"er indication 9ym)tom diary 9elf ta=en swabs
H euivalent to doctor
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0ecurrent VVC
I GUM referral
$ould try regime recommended by
M99#: but unlicencedJ 'luconaole PO ,!!mg wee=ly x 1
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Contraception recurrent VVC
*"et"er )ill causes ##$ unclear
:e)oProvera )rotective
H small retros)ective study
H reduced $andida colonisation in)ros)ective study
7or)lant associated wit" reducedincidence of vaginitis
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*lternative+ treatment
:ue to Kovergrowt" of $andida inbowelIIIII
og"urt and lactobacillus acido)"ilus H lactobacillus vaginal flora not )rotective H intravaginal ineffective but soot"ing (issc"o) MP& et al -e+
Ti+sch Genees/ ,-3C.131/,5-2,1,
H yog"urt effective growt" media for $andida
H Oral lactobacilli may be effective Dilton E et al Ann Int *e+ ,--.116/656265C+
H IIato)y mediated ;solauri E et al Am J 0lin -utr !!,.73/0009205!9+Nallioma=i M& et al 1,ncet !!,.357/,!C12,!C-+
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Summary
7o )at"ognomic feature ;tc"ing is only )redictive sym)tom