VAGINAL CANDIDIASIS

Venue: Bushenyi Medical Centre

Date: 06/08/2012

Presenter: Dr Mutabazi Sharif MBchB

THE VAGINA

VAGINAL CANDIDIASIS

Vulvovaginal Candidiasi accounts for 1/3 of vaginitis cases. Candida species are part of the normal flora in 2050% of healthy asymptomatic women. 75% of premenopausal women report atleast one episode 50% of young females have had vaginal candidiasis(Hurley et-al Post grad Med J. 1979;55(647):645)

VAGINAL CANDIDIASIS

3-4% of prepubertal girls affected.

AETIOLOGY

Candida albicans 80-92%

Non Albican species e.g. C. glabrata, C. tropicalis, C. krusei, C. parasilosis, and Sachromyces cerevisiae, C. stellatoidea(Van Dyck et-al 1999) The organisms are endogenous but can be sexually transmitted. Changes in vaginal environment are necessary before the organism can induce pathological effects.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

Under normal circumstances, the vagina maintains a balance among its normal flora which regulate its moisture and PH. Vaginal flora predorminantly consists of lactobacillus, corynebacteria and Candida. Others are: Streptococcus, Bacteriodes,Staphylococcus and Peptostreptococcus. These maintain vaginal PH Btn 3.8-4.2 to prevent overgrowth of yeast and

PATHOPHYSIOLOGY
Bacteria. Lactobacillus and Corynebacteria maintain the PH by converting glycogen to lactic acid. The normal discharge is clear to milky in , odourless and non irritating. The discharge may change thickness during the menstrual cycle as levels of hormones fluctuate. The primary cause of candidiasis is disruption of normal vaginal flora which can happen with the following risk factors.

RISK FACTORS

Immunosupression e.g. HIV , Bone marrow malignancies and other cancers Diabetes Mellitus Hormonal Contraception Recent antibiotic use Specific immunological deficits Tight clothes (panties or knickers) Stress Prolonged steroid use.

RISK FACTORS

Use of panty liners Pregnancy Sharing towels with infected persons Sexual Intercourse(Un protected), not well studied but some studies suggest that it is likely Bacterial Vaginosis

RISK FACTORS

Dermatological Conditions like Psoriasis and Lichen planus

Feminine hygiene products

SYMPTOMS

Vulvar itching
PV Discharge. White milky curdy or cottage cheese discharge, odorless Superficial dyspareunia External Dysuria

Vulval soreness

SIGNS

Erythema
Fissuring Non offensive discharge, cottage cheese-like/curdy Oedema Excoriation

Satellite leisions

CLINICAL APPEARENCE

CLASSIFICATION

Sporadic. Less than 4 episodes in 12 months

Recurrent: 4 or more episodes in 12 months Re-infection: Relapse within two months of first episode. Complicated/Non complicated.

TREATMENT

Depends on whether it is complicated or not

Complicated VVC is one where; There are severe symptoms(subjective) Client has HIV , Pregnant, Recurrent(more than 4 episodes in 1 year), Diabetes, Non albicans species.

INVESTIGATIONS

INVESTIGATIONS

High Vaginal Swab. Gram stain and Wet Mount.

Cultures using Sabourads agar especially for recurrent VVC. Latex Agglutination tests RCT

FBS

MICROSCOPIC APPEARANCE

TREATMENT

Butoconazole 2% cream 5 g intravaginally for 3 days Butoconazole 2% cream 5 g (butoconazole 1 sustained release), single intravaginal application Clotrimazole 1% cream 5 g intravaginally for 7-14 days Clotrimazole 100 mg vaginal tablet for 7 days Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days

TREATMENT

Miconazole 2% cream 5 g intravaginally for 7 days Miconazole 100 mg vaginal suppository, 1 suppository for 7 days Miconazole 200 mg vaginal suppository, 1 suppository for 3 days Miconazole 1200 mg vaginal suppository, 1 suppository for 1 day Nystatin 100,000 unit vaginal tablet, 1 tablet for 14 days

TREATMENT
Fluconazole 150/200 One tablet single dose. The choice between oral and topical treatment depends on availability, cost and individual preference. Severe VVC. Give topical therapy for 7-14 days. Addition of a steroid cream is beneficial. Or Give Fluconazole 150mg or 200 mg repeated in 72 hours.

RECURRENT VVC

More than four episodes in 12 months with atleast two episodes documented by microscopy. Analysis of vaginal isolates from women with recurrent VVC reveals non albicans species and resistance to imidazoles is rarely the cause. Studies have implicated Candida antigen specific immunodeficiency.

TREATMENT OF RECURRENT VVC

INDUCTION PHASE: 7-10 days of topical therapy OR 100 mg /150mg oral dose of fluconazole on the 1st,4th and 7th day.

MAINTANANCE PHASE: Oral Fluconazole 100mg or 150 mg or 200 mg of fluconazole weekly for 6 months

TREATMENT
ALTERNATIVES FOR INDUCTION& MAINTANANCE. Topical Therapy for 10-14 days depending on response. Then clotrimazole pessaries 500mg weekly for six months. If relapse between doses, consider fluconazole 150/200 mg twice weekly or 50 mg daily.

Position for Insertion of Pessaries

ROLE OF ALLERGY

If this is established, especially for patients not responding to fluconazole suppressive therapy, cetrizine 10 mg POS daily for six months. This should be considered in women with atopy, psoriasis or lichen sclerosus.

NON ALBICANS VVC

Established from culture tests or resistant candidiasis to responding to supressive therapy. Use boric acid vaginal suppositories 600 mg for 2-3 weeks OR intravaginal flucystosine1g pessary or 5g cream for two weeks.

PARTNER TREATMENT

CDC does not recommend routine partner treatment as well as ACOG.

Some studies have shown benefit with partner treatment. Clinicians can consider partner treatment or not until evidence is conclusive.

PATIENT COUNSELLING

Candida is commonly not sexually transmitted Avoid tight clothing Allowing the vagina to dry after showering or swimming Cleansing the vagina(Front to back) Abstain during treatment Condoms and diaphragms not reliable with topical treatment. Avoid the risk factors if possible.

HOW SHOULD A WOMAN CLEAN HER ANUS?