Vulvovaginitis may have an infectious cause, a non-infectious cause or a combination of both. A vaginal swab is usually needed to establish the diagnosis even though Candida albicans is the commonest infectious cause. Treatment of vulvovaginitis may require modification of the vaginal environment. Specific treatment for C. albicans involves inserting an antifungal drug into the vagina when the patient is symptomatic. Patients with recurring infections may need long-term prophylaxis with an oral antifungal drug. The diagnosis must be reviewed if patients do not respond to treatment.
Candida albicans is the commonest cause of vulvitis and vaginitis. However, it is not the only cause and the clinician must be aware of the common conditions which produce similar symptoms (Table 1). Vaginal swabs and vulval biopsy are the most useful tools for differentiating these conditions.
Myths, traps and sexual sequelae
Candida reaches the vagina via oral ingestion. It is not sexually transmitted. It is therefore unnecessary to recommend treatment of the male partner unless he has candidal balanitis or another form of cutaneous candidiasis in the genital area.
C. albicans infection is an oestrogen dependent disorder. It therefore seldom occurs in healthy children, women who are breastfeeding or postmenopausal women unless they are on relatively high doses of oestrogen replacement. The infection almost always occurs within the insensitive vaginal lumen. The resultant 'burning' of the sensitive vulval epithelium is caused by the yeast's metabolites (seldom by infection of the vulval skin). Treatment must be directed to the vaginal source of the infection. Applying antifungal preparations to the vulva will not only be ineffective but will also worsen the contact dermatitis which is a feature of the complaint.
Mixed pathology is common in the vulval area. The commonest combination is vulval dermatitis exacerbated by bouts of candidiasis. Swabbing as often as necessary is the only means of selecting the appropriate treatment. The inappropriate use of antifungal applications can make the dermatitis worse as these products are relatively toxic to genital epithelium.
Candida species other than albicans are being diagnosed with increasing frequency. Examples are Candida glabrata, krusei, parapsilosis and tropicalis. These non-albicans yeasts are relatively non-pathogenic and rarely, if ever, require treatment. This is fortunate, because they are generally resistant to the usual antifungal drugs, and the over-the-counter availability of these treatments is probably why these yeasts are being selected out and appearing more often. This is also why pathologists must identify the species in all cultures positive for Candida.
Any woman who has genital discomfort for longer than, say, six months may develop impairment of sexual arousal. Dyspareunia can result from a combination of coital physical, chemical and biological trauma.
Recurrent candidiasis is an undoubted problem and the vast majority of sufferers are healthy women. I am unaware of any dietary regimen, so-called 'natural products' or lifestyle modification (other than prolongation of breastfeeding) which makes any significant difference to the incidence of this complaint. The vast majority of these patients will not be diabetic. Glucose tolerance testing is indicated in the more difficult cases and always in the postmenopausal woman with C. albicans infection if she is not receiving hormone replacement therapy.
General principles of treatment
The importance of having a vaginal swab taken before starting any treatment needs to be particularly emphasised to the patient. If the patient does not respond as you would expect to your first treatment, stop everything and think again. Is your diagnosis correct? There is no place for the empirical use of vaginal antifungals if the patient does not get a complete and prolonged response to a one week course.
Patients' personal care
Inflamed epithelium is hypersensitive to chemical and physical trauma, therefore special care needs to be taken and only normal saline can be guaranteed safe for washing. Most patients will benefit from avoiding soap and other cleansing agents and bathing the area with normal saline (salt, two teaspoons to the litre) applied with cotton wool and gently patted dry with a soft towel. For the same reason, patients should be advised not to use home remedies, over-the-counter preparations and non-prescribed medication. In the sexually active, the avoidance of artificial lubricants should be discussed.
Treatment of C. albicans infection
Many preparations are effective in the treatment of candidiasis. A vaginal imidazole, inserted nightly for one week, is recommended as the standard treatment for candidal vulvovaginitis.
Treatment of recurrent candidiasis
There is no generally agreed definition of recurrent candidiasis. However, the infection may be deemed recurrent if there is a proven recurrence less than six months after a similar episode has been successfully treated. Unless further measures are undertaken, experience suggests that recurrences, at an unacceptable frequency, are likely.
Laboratory confirmation of each suspected infection is an integral part of the management. The woman should be advised to have a vaginal swab taken whenever she suspects a recurrence.
There are several strategies for the prevention of recurrent infection. One week of a vaginal imidazole is still the treatment of choice when clinical (proven) infection occurs.
Alteration of the vaginal environment
This may be accomplished by a change of contraception to depot medroxyprogesterone acetate (which provides oestrogen-free ovulation suppression). For women taking hormone replacement therapy a lower dose of oestrogen can be used.
Long-term vaginal therapy
The nightly insertion of one million units of nystatin in a vaginal cream, tablet or pessary (including during menstruation) can virtually be guaranteed to keep a woman free of candidiasis without producing any significant discharge during the day. This therapy should continue for six months in the more troublesome cases. It is the treatment of choice for pregnant women who have had more than one proven infection during the pregnancy. This prophylaxis should not be stopped until the onset of labour.
Long-term oral therapy
Ketoconazole, fluconazole and itraconazole are effective oral anticandidal drugs available in Australia. They do not attain a concentration in vaginal secretions which is sufficient for them to be recommended as the sole treatment for clinical infection but they are definitely effective for prophylaxis. There is evidence that fluconazole is the most effective and least toxic but, at the usual dosage of 100 mg orally twice weekly (for prophylaxis), the patient will pay almost $40 a week.
Ketoconazole 200 mg orally daily is over 80% effective in preventing recurrences, but reports of hepatotoxicity and occasionally other adverse effects reduce its attractiveness. Sometimes recurrences will occur unless the dosage is raised to 200 mg twice daily. Ketoconazole requires an authority prescription if it is supplied by the Pharmaceutical Benefits Scheme. Six months continuous treatment is recommended.
Treat each recurrence thoroughly
Many women, given ready access to microbiological diagnosis and safe in the knowledge that they can get rapid treatment for each recurrence, will settle on just that - medication with each proven recurrence. In the event of multiple recurrences I would recommend 14 days continuous use (including during menstruation) of a vaginal imidazole cream and a simultaneous course of ketoconazole 200 mg twice daily for five days. In many cases this regimen will reduce the frequency of recurrences.
Doctors James Scurry and Rod Sinclair were largely responsible for the classification of vulval disorders from which Table 1 has been extracted. I wish to thank Dr Sam Sfameni for his suggestions in the preparation of this article.