Overview
Also known as genital thrush, vulvovaginal candidiasis is an infection of the vulva and vagina with Candida fungi, mostly Candida albicans. Candida species are part of the normal flora of the mucous membranes, but their overgrowth can cause infection and inflammation, leading to vaginal irritation and a non-offensive discharge.
Definitions
Acute infection is when a single presentation of vulvovaginal candidiasis occurs and Candida species are usually detected by microscopy/culture.
Recurrent infection is defined as 4 or more symptomatic episodes in one year, ideally with at least 2 episodes confirmed by microscopy/culture.
Treatment failure is defined as a failure of symptoms to resolve within 7-14 days of treatment.
Causes
Epidemiology
- Vulvovaginal candidiasis is very common and around 1/5 of people of reproductive age may be colonised with asymptomatic Candida species
- Around 3/4 of people will have at least one episode of vulvovaginal candidiasis in their lifetime
- Less than 5% of people have recurrent vulvovaginal candidiasis
Risk Factors
Most people have no clear risk factor, however, some can include:
- Recent antibiotic use – which can alter normal vaginal flora
- Non-compliance with treatment
- Local irritants – such as douching, soaps, and shampoos
- Uncontrolled diabetes mellitus
- Immunocompromise – such as HIV, corticosteroid use, and immunosuppressant drugs
- Pregnancy
- Endogenous and exogenous oestrogen – Candida species are usually found in pubertal/post-pubertal people and exogenous oestrogen (e.g. the combined oral contraceptive pill) may cause overgrowth and infection
Presentation
Features of vulvovaginal candidiasis include:
- Vulval/vaginal itching – the most common feature
- Vulval/vaginal soreness/irritation
- Abnormal vaginal discharge – often white, ‘cottage cheese-like’, and non-offensive
- Superficial dyspareunia
- Dysuria
- Erythema and satellite lesions may be seen
Investigations and Diagnosis
Overview
Tests are not routinely indicated if the diagnosis is clear. Investigations may be considered if there is uncertainty and/or symptoms are persistent or recurrent. They may include considering:
- High vaginal swab and culture – first-line, should be done in recurrent vulvovaginal candidiasis
- HbA1c testing – to exclude diabetes mellitus in severe/recurrent infection
- Sexually transmitted infection (STI) screening – if the person is concerned, at risk, or there are features of an STI
Management
Overview
For non-pregnant people:
- 1st-line: single dose oral fluconazole
- If contraindicated/inappropriate: clotrimazole intravaginal pessary
- If there are vulval symptoms, consider adding topical imidazole
For pregnant people:
- Avoid oral antifungals as they are contraindicated
- Offer local treatments – such as a clotrimazole intravaginal pessary
Recurrent vaginal candidiasis
For people with recurrent vaginal candidiasis:
- Check compliance
- Perform investigations for:
- Confirming candidiasis – via a high vaginal swab for culture
- Screening for diabetes – via HbA1c
- Consider an induction-maintenance regime such as oral fluconazole every 3 days for 3 doses followed by oral fluconazole weekly for 6 months
Complications
Treatment failure – may happen in up to 20% of people receiving imidazole treatment.
Recurrent infection – some people may have poor/partial responses with symptoms persisting between treatments.
Candidal balanitis in male partners – this is rare. See balanitis for more.
