Candida vulvovaginitis

Candidiasis vulvovaginitis is one of the most common pathologies in women of reproductive age. The disease is characterized by an inflammatory process provoked by different species of fungi of the genus Candida. Treatment is carried out until the elimination of pathological symptoms.

Is candida vulvovaginitis a thrush?

Candidiasis vulvovaginitis or thrush is a pathology that develops as a result of increased activity of the opportunistic fungal flora Candida. Such flora is normally present on the mucous tissues of the human body, but the inflammatory process and the corresponding pathological symptomatology occur when the balance of vaginal microflora is disturbed. [1] It is favored by lowered immunity, various infectious diseases, other inflammatory processes. The problem is accompanied by unpleasant sensations, pathological discharge appears, there is an unpleasant odor, etc. Candida vulvovaginitis is the cause of about one third of cases of vulvovaginitis. [2].

The difference is that thrush can manifest itself not only in the form of vulvovaginitis. Candidiasis often affects the oral cavity and the urinary system, including in men.

Only a specialist can determine the type of disease and make the correct diagnosis after conducting the appropriate diagnostic measures.

Epidemiology

Candidiasis vulvovaginitis for many years is the leader among gynecologic inflammatory diseases in women. The frequency of pathology is quite high:

• at least 75% of women have had candidal vulvovaginitis at least once in their lifetime;
• At least 50% of women had recurrent episodes of the disease;
• about 8% have frequent, persistent vulvovaginal candidiasis. [3]

In general practice, it is believed that candidal vulvovaginitis causes 15-30% of the symptomatology of inflammatory processes of the lower genital tract. Therefore, the disease can be attributed to the most common among all gynecological disorders.

To date, there are descriptions of more than 170 biodiversity representatives of yeast-like fungal flora. Among them, the overwhelming number - more than 85% is Candida albicans.

Asymptomatic carriage of candidal flora occurs in approximately 18% of non-pregnant patients of childbearing age.

Causes of the candidal vulvovaginitis

It is known that the fungal flora is normally present in the normal microbiome of the oral cavity, vagina, large intestine. Among the more than one and a half hundred isolated varieties of Candida, only nine are considered pathogenic for the human body. About 90% of all strains of yeast fungal infection found in the vagina of patients with candidal vulvovaginitis is Candida albicans. Much less common, but still occur Candida glabrata, tropicalis, parapsilosis. The symptomatology of these lesions does not usually differ, although the proven most frequent causative agent of candidal vulvovaginitis, Candida albicans, is less frequently associated with a persistent form of the disease. However, Candida is part of the normal flora in many women and is detected in 10% of asymptomatic women. [4]

Candida vulvovaginitis most often starts on the background of low immunity. The pathogen begins to actively multiply, the first symptoms, discomfort, discharge appear. [5]

An increase in fungal infection is most often associated with:

• with stress;
• general dysbiosis, diabetes imbalance;
• infectious inflammation;
• with pregnancy, other hormonal changes;
• with the use of immune-suppressing medications and antibiotics;
• with poor diet, eating a lot of sweets;
• with the presence of chronic diseases that weaken the body's immune defenses;
• with insufficient intimate hygiene, frequent use of synthetic pads and poor quality underwear.

Risk factors

There are a number of factors that contribute to the development of vulvovaginitis, but do not act as direct causes of the pathological process. Such factors include:

• poor compliance with the rules of intimate hygiene, untimely replacement of underwear and absorbent pads;
• promiscuous sexual relations;
• The occurrence of diaper rash in the folds of the external genitalia (e.g. Obesity);
• dermatologic diseases (eczema, psoriasis);
• uterine prolapse, vaginal prolapse;
• anal fissures, rectovaginal pathologies, hemorrhoids;
• Abscesses, carbuncles and furuncles located in close proximity to the genitals;
• periods of intense hormonal surges, including pregnancy;
• chemotherapy, antibiotic therapy, hormone therapy;
• radiation therapy;
• various chronic diseases of the reproductive organs;
• sharp drop in immunity, prolonged infectious pathologies, tumor processes, surgical operations.

Patients with recurrent candidal vulvovaginitis, defined as 4 or more episodes of culture-confirmed candidal vulvovaginitis, have predisposing genetic factors that make them susceptible to recurrent fungal infections. These factors may also cause a predisposition to Candida hypersensitivity reactions. [6]

Pathogenesis

Candidiasis vulvovaginitis is an infectious disease affecting the vulva and vagina. The process is provoked by yeast-like fungi belonging to the genus Candida. It affects both women of active childbearing age and girls or menopausal women.

The pathogenesis of the development of candidal vulvovaginitis is quite complex and not fully understood. Candida strains, which are detected in patients with this disease or in carriers of fungal infection, have the same biochemical parameters. Therefore, it can be concluded that the importance of the general state of the body in the development of the infectious process is not insignificant.

Development proceeds in stages:

1. Fungal adhesion to mucosal tissue.
2. Dispersal of the pathogen through the mucosal tissue.
3. Penetration of fungi into the epithelial layer by overcoming the membrane of the mucosal epithelium, further penetration into the connective tissue structure.
4. Entry of the infection into the vascular network, spreading it to other organs and systems.

The mild course of the disease may stop at any one of these stages.

In most cases, only the superficial layers of the vaginal epithelium are affected, but this process can last for years. A change in the balance of the microbiome can provoke an exacerbation of the disease, or lead to remission or recovery. [7]

Symptoms of the candidal vulvovaginitis

Regardless of the provoking factors, the symptomatology of candidal vulvovaginitis is almost always the same, and depends only on the stage of the fungal process.

The acute course of the disease is characterized by vivid manifestations of an intense inflammatory reaction. The first signs are usually represented by itching and painful sensations, with their intensification at urination or sexual contact, motor activity.

During the preliminary examination, swelling of the labia, redness of the vulva and the inner thighs or perineum may be noticed. The formation of erosions in the area of external genitalia is possible. Neurotic symptomatology, insomnia may occur.

Discharges in candidal vulvovaginitis can be both abundant and moderate, often of the type of "curd mass", less often - watery, turbid-greenish, with an unpleasant odor.

Neglected stages of candidal lesions may be accompanied by ascending infection: patients are found oophoritis, endometritis, salpingitis, and relapses occur under the influence of even the slightest hypothermia or dietary errors (consumption of sweets, spicy spices, etc.).

Candida vulvovaginitis in children

Candida vulvovaginitis in girls under 18 years of age is also caused by yeast-like fungi of the genus Candida. The main cause of infection in newborns is infection during labor from a carrier mother. During the passage of the baby through the birth canal, representatives of fungal flora are retained on the skin and mucous membranes, which subsequently begin to actively multiply and develop. In addition, infection is possible if the baby is bathed in a bathtub in which a family member with candidiasis previously washed.

In adolescence, candidal vulvovaginitis can occur against the background of intense hormonal changes.

In many cases, increased multiplication of fungal flora is observed:

• with prolonged and haphazard antibiotic therapy;
• with a sharp drop in immunity, frequent colds;
• in diabetes mellitus, metabolic disorders, allergies, bronchial asthma;
• for frequent digestive distress;
• in premature infants;
• in dry, hot conditions;
• living in unfavorable sanitary and hygienic conditions.

The diagnosis of the child is made by a pediatrician on the basis of examination and the results of laboratory and instrumental diagnostics.

Candida vulvovaginitis in pregnancy

Intense growth of fungal infection during pregnancy is a fairly common phenomenon. Most often the problem is detected at the end of the second trimester or at the beginning of the third trimester. It is important to identify the disease in time and eliminate it before the onset of labor, which will help to exclude the development of complications, infection of the baby.

The risks of developing candidal vulvovaginitis are significantly higher in those expectant moms who have had candidiasis at least once before pregnancy.

Almost immediately from the moment of conception, the female body undergoes significant changes that dramatically affect the work of all systems and organs. The hormonal status changes, the production of female sex hormones increases, the immune system is suppressed, which, in particular, should control the activity and ratio of opportunistic microorganisms. In addition, strong hormonal surges change the balance of microflora inside the vagina, which significantly increases women's susceptibility to all kinds of infections.

If a pregnant woman with candidal vulvovaginitis is treated in a timely and competent manner, there are no risks for her or the future child. If the disease will progress, and the patient will refuse treatment, fearing to harm the fetus, the consequences can be quite unfavorable. It is important to realize that modern pharmaceutics has a large number of drugs that are safe for use during pregnancy. Such drugs successfully cope with candida infection and do not pose a threat to the future child.

Forms

According to the variants of the course of chronic candidal vulvovaginitis (lasts more than three months), acute (less than one month) and subacute vulvovaginitis (runs from one to three months).

By the nature of the course distinguish persistent (steady course) and recurrent candidal vulvovaginitis (runs with frequent exacerbations and remissions).

Depending on the etiology, vulvovaginitis is not only candidal, but also bacterial, irritative, allergic, specific. Among specific ones, tuberculous, gonorrheal, syphilitic, syphilitic, trichomonadal, and less often viral vulvovaginitis are the most common.

Also separately distinguish candidiasis, which is typical of the absence of symptoms and the detection of yeast-like fungi in small quantities during microbiological diagnosis.

Complications and consequences

At first, candidal vulvovaginitis may have a vague, low-expressed symptomatology, which is especially noticeable during periods of menstrual bleeding against the background of changes in the vaginal environment. If the problem is not treated, the disease will progress. The risk of developing all sorts of complications increases, such as:

• hyperemia of mucous tissues in the genital area;
• the formation of microfractures, ulcers;
• frequent recurrent exacerbations of candidal vulvovaginitis;
• spread of infection to nearby tissues and organs;
• frequent inflammatory processes of reproductive and urinary organs;
• immune weakness;
• infertility.

Unfavorable consequences occur if a woman ignores the treatment of this disease during pregnancy. There are rare cases when fungal infection penetrated the placental membrane, leading to intrauterine infection of the fetus. However, most often, babies are infected with candidiasis during labor, during the progression through the affected birth canal.

Complicated forms of candidal vulvovaginitis are dangerous not only for the future baby, but also for the woman herself. Massive fungal flora negatively affects the condition of vaginal tissues, reduces the indicators of their strength and elasticity. Therefore, in the process of labor in patients with candidal vulvovaginitis significantly increase the risk of tissue trauma, blood loss and so on.

In addition, the disease contributes to the start and progression of erosive vaginal and uterine processes. Erosions may subsequently cause the development of other pathologies, including tumors.

Side effects that may occur with antifungal treatment include abdominal pain, nausea and vomiting, diarrhea, flatulence, headache, central nervous system disorders, musculoskeletal disorders, rash, allergic reactions, menstrual irregularities, and alopecia. [8]

Diagnostics of the candidal vulvovaginitis

Diagnosis of candidal vulvovaginitis is a rather complex issue, since yeast-like fungal flora and normally inhabit the body, and the detection of Candida against the background of the absence of symptoms does not become an indication for the application of therapeutic measures.

It is important to connect a comprehensive diagnostic scheme with some considerations in mind:

• The presence of symptoms of candidal lesions of the skin and mucous membranes;
• microscopic examination with Gram staining, detection of massive pseudomycelium and fungal budding;
• sowing of secretions on nutrient media, counting colony-forming units (in candidal vulvovaginitis CFU is more than 10³/ml);
• Assessment of colony pattern and variation in fungal growth;
• detection of the candida pathogen on the tissues on which it should not normally be - for example, in the lungs, urine, liquor;
• detection of positive humoral and cellular immunoreactions, positive skin tests;
• detection of fungal infection by biopsy according to a specific tissue reaction.

In general, the diagnosis of candidal vulvovaginitis is made by considering the combined clinical and laboratory information. Laboratory diagnosis usually includes the following tests:

• direct methods of Candida detection (microscopy of a native or stained smear, culture on appropriate media, polymerase chain reaction with detection of DNA of the pathological agent); [9]
• indirect methods of Candida detection (serologic techniques IgG, IgM).

The "gold standard" is considered to be the culture method of diagnosis. It allows both to detect fungal infection and to determine its number and sensitivity to antifungal drugs. It is important to take into account that in this case for a positive result it is necessary to comply with all pre-analytical recommendations. [10]

Instrumental diagnostics are most commonly presented:

• traditional chairside examination, vaginoscopy (in pediatrics), cervicoscopy;
• colposcopy;
• Pelvic ultrasound.

Differential diagnosis

In the course of differential diagnosis, the doctor specifies the nature of the disease (fungal, microbial, viral, allergic, specific vulvovaginitis, etc.).

In order to exclude various inflammatory processes affecting the uterus and appendages, ultrasound diagnosis of the pelvic organs is performed.

In chronic recurrent vulvovaginitis may require consultation of specialists of narrow profile, such as allergist, endocrinologist, dermatovenerologist, urologist, surgeon, phthisiatrist, etc.

Nowadays, express diagnostic methods are increasingly used, which allow the exact determination of the fungal strain in the shortest possible time. For this purpose, ready-made test systems are used, which have a favorable environment for the growth of fungal flora. The use of express methods is considered a rather promising direction that does not require a large period of time. Nevertheless, the results of such diagnostics do not give an idea of the associated types of microorganisms.

If we are talking about severe recurrent candidal vulvovaginitis, occurring against a background of marked immune disorders, it is sometimes practiced to assess the titer of antibodies to Candida pathogens in serum. Although this technique is not sufficiently accurate, the results (both positive and negative) are often false.

The problem is complicated by the fact that in more than 80% of cases the causative agent of recurrent pathology is a mixed fungal (candida) flora, resistant to the most common antifungal drugs.

Treatment of the candidal vulvovaginitis

Acute candidal vulvovaginitis is treated with antifungal agents. Since most cases of candidal vulvovaginitis are secondary to C albicans species and C albicans does not show resistance to azole antifungals, these drugs are the drugs of choice. [11]

Complex exposure - this is the primary task for the doctor. Standardly prescribed antifungal agents in the form of suppositories, tablets, vaginal ointments.

The most common medications for candidal vulvovaginitis:

• Pimafucin is the latest drug approved for use during pregnancy and breastfeeding.
• Livarol - vaginal suppositories, contraindicated in the early stages of pregnancy.
• Mycosone is an antifungal agent in the form of vaginal suppositories, vaginal cream.
• Gyno-Pevaril is a drug based on econazole, has the ability to penetrate deep into the tissues, inhibiting the development of fungal infection. Among the possible side effects of vaginal suppositories: irritation of the mucous membrane, burning.
• Zalain - candle is used once, inserted deep into the vagina before going to bed. It is allowed to reapply Zalain after 1 week.
• Clotrimazole is a common drug with pronounced antibacterial, antifungal and anti-inflammatory activity. Clotrimazole is not prescribed in the first trimester of pregnancy.
• Diflucan, Fluconazole, Fucis, Flucostat - take once a day in the amount of 150 mg. With relapses, it is possible to periodically repeated monthly intake of 150 mg. The total duration of therapy varies within 4-12 months. Side effects in the form of dizziness, nausea, headache are possible.

Antifungal agents can be administered by several methods, including a single oral dose of fluconazole 150 mg or terconazole administered intravaginally once, or as multiple dosing regimens for 3 to 7 days, which are available over-the-counter. These options are equally effective in patients with uncomplicated disease (e.g., immunocompetent status or nonrecurrent candidal vulvovaginitis). Thus, treatment decisions may be based on cost, patient preference, and drug interactions. In patients who do not respond to treatment, culture may be required to look for other Candida species, often resistant to standard therapy. [12]

In complicated candidal vulvovaginitis, including patients with immunosuppression or recurrent infection, extended treatment regimens such as intravaginal azole therapy for at least 1 week or oral fluconazole treatment at a dose of 150 mg (renal adjusted CrCl <50 mL/min.) ) once every 3 days for 3 doses. Patients with recurrent candidal vulvovaginitis may benefit from suppressive therapy with oral fluconazole weekly for 6 months. However, oral antifungal agents should not be administered to pregnant women. A 7-day course of intravaginal treatment is recommended for such patients. Fluconazole is considered safe for breastfeeding women. [13] Non-pharmacologic therapy (e.g., intravaginal or oral yogurt therapy, intravaginal garlic administration, or spritzing) has not been effective.

Meanwhile, the drug of choice in the treatment of candidal vulvovaginitis is Itraconazole, a highly active antifungal drug that acts, including on strains that do not show sensitivity to Fluconazole. Under the influence of Itraconazole, the fungal cell dies, recovery occurs. The drug is represented by the active metabolite hydroxyitraconazole, prolonging the therapeutic activity even after the completion of the medication. Active substances are concentrated in the tissues of the genital organs 4 times more than in the blood.

Itraconazole is prescribed for acute candidal vulvovaginitis:

• 200 mg twice a day (course - 1 day);
• 200 mg once a day (course - 3 days).

Itraconazole is used for relapse of chronic candidal vulvovaginitis:

• 200 mg daily for one week against the background of local methods of treatment, as well as 200 mg on the first day of the monthly cycle for several months (up to six months);
• the sexual partner is also treated at the same time.

Physiotherapy treatment

The following physical therapy methods may be used in the treatment of persistent candidal vulvovaginitis:

• Laser therapy - has anti-inflammatory and analgesic effects, strengthens local immunity, improves blood circulation in the tissues and pelvic organs.
• Magnetotherapy - eliminates pain syndrome, helps to get rid of infectious and inflammatory processes in the reproductive system, accelerates the recovery of diseased and damaged tissues.
• Ultraphonophoresis - increases tissue permeability, improves drug penetration to the focus of inflammation.
• Ultrasound therapy - eliminates pain, blocks the development of inflammatory reaction, improves local blood circulation.

Physiotherapy procedures are safe, are not accompanied by side effects, well complement the main treatment.

Herbal treatment

Folk methods of treatment are often used, both for candidiasis and other types of vulvovaginitis. They use mainly decoctions and infusions of various medicinal plants. Among the most popular recipes are the following:

• Decoctions for oral intake (oak bark, nettle leaves, ergot, medicinal calendula, etc.). Systemic use of such decoctions helps to strengthen the body's defenses, improve the protective properties of mucous tissues.
• Chamomile, calendula and sage infusions for diapering and spritzing. These plants have anti-inflammatory and antifungal effect.

If we are talking about neglected vulvovaginitis, as well as atrophic changes in the mucous tissues, then here the use of herbs is not recommended, because such treatment will not be enough. It is important to consult doctors in a timely manner and undergo a full-fledged anti-candida and tonic therapy.

Prevention

Preventive measures include careful adherence to recommendations on intimate hygiene (especially in the presence of obesity, at high temperatures in the room), timely replacement of underwear and sanitary pads, wearing underwear made of natural fabrics. It is important to consider that synthetic fabrics do not provide normal skin "breathing", contribute to increased concentration of sweat, which creates favorable conditions for the growth of pathogenic flora.

It is desirable to exclude promiscuous sexual relations, do not practice unprotected sex (especially with casual partners).

It is important to eat healthy quality food and control body weight. The diet should be enriched with vegetable products (greens, vegetables, berries and fruits), fermented milk products, cereals. Do not consume large quantities of baked goods, sweets, animal fats and spicy spices.

Any medication (including hormonal contraception) should not be taken without first consulting a doctor. If you are prone to fungal infections, you should inform your doctor.

In no case should not be abused sprays, "prescribe" them to themselves. Frequent and chaotic sprays lead to the washout of beneficial microorganisms from the vaginal mucosa, as well as to the disruption of a healthy bacterial balance.

It is recommended to visit your gynecologist regularly for preventive checkups.

Forecast

With timely diagnosis and treatment, the prognosis of the disease can be considered favorable. Despite appropriate treatment, recurrences are relatively common and are estimated to be between 14% and 28% in healthy individuals. [14] Most often, recurrence of the disease is due to persistent vaginal microorganisms or endogenous re-infection with an identical strain of Candida. Less frequently, the disease may be caused by a new strain of Candida. Recurrence may be triggered by antibiotic use, sexual activity or dietary factors. Genetic predisposition may also affect a person's risk of recurrence.

Working on new therapies using previously known antifungal agents of sufficient spectrum of activity, evaluating the possibilities of simultaneous influence on infectious agents and all probable foci of infection to prevent recurrences is an important task of medicine.

Qualified treatment is usually effective. After laboratory and instrumental examination, the doctor prescribes appropriate medications, gives recommendations on hygiene and lifestyle. Candidiasis vulvovaginitis is better treated in the initial stages of development, so it is better to seek medical help at the first symptoms. This will avoid serious complications, prevent the transition to a chronic course of the process.