Candidiasis vulvovaginale B37.3

Acute, chronic or chronically recurrent inflammatory infection of the vulva and/or the vagina caused by yeast fungi of the genus Candida, wherein a plurality of promoting factors (e.g. intestinal candidosis, diabetes mellitus, frequent antibiotic systemic therapies, oral contraceptives, glucocorticoids) in the region of the vulva and the vagina.

Candida albicans (80-90%)

Candida glabrata (5-10%)

Candida krusei (3-5%)

furthermore C. parapsilosis, C. guilliermondii. and others

• vulvacandidosis:
  • Vesicular or pustular form
  • Diffuse eczematous form
  • Follicular form.
• vaginal candidiasis:
  • Light form (without clear colitis)
  • Moderately severe form (signs of inflammation in the sense of colpitis)
  • Severe vaginal candidosis (severe colitis).
• Chronic recurrent vulvovaginal candidosis, CRVVC (=/> 4 recurrences within one year)

75% of women develop vulvovaginal candidiasis at least once in their lives. About 5% of patients suffer from chronic recurrent vulvovaginal candidosis - CRVVC (by definition: at least 4 recurrences per year).

• Vaginal colonization with yeast fungi:
  • 10-20% in healthy non-pregnant premenopausal women.
  • 20-30% in untreated pregnant women at birth.
  • 5-10% in all non-pregnant women.
  • > 30% in case of immune deficiency or immunosuppression.
  • Predisposing factors: Oral anticontraceptives, pregnancy, diabetes mellitus, immunosuppressive therapy, HIV infection.
• risk groups:
  • Younger sexually active women with frequent partner change
  • Prostitutes
  • Positive medical history for: pelvic inflammatory disease, extrauterine pregnancy, sterility problems, urethritis, STD.

Vaginal or vulvar colonization with yeast fungi of the genus Candida. Colonisation is usually via the partner's own orointestinal tract or that of the partner, which may also be colonised in semen with the same yeast strain. The vaginal yeast colonization depends on the glucose supply in the vagina.

Frequency:

• C. albicans about 80%.
• C. glabrata 5-10
• C. crusei 1-3
• Rare: C. tropicalis, C. parapsilosis, C. guilliermondii.

Whitish, partly crumbly fluor vaginalis, oedematous swelling and reddening of the vaginal mucosa with wipeable whitish deposits, pruritus, burning. In severe forms of colpitis up to necrotizing colpitis.

C. albicans infections(80% of the infections) regularly progress with itching and burning as well as with colpitis and/or vulvitis.

C. glabrata infections (about 10% of infections) are asymptomatic; occasional itching and mild burning are reported; vulvitis is very rare.

Clinical inspection of vulva and vagina.

Native preparation from vaginal secretion:

• Vaginal secretion is applied to a slide and mixed with a drop of saline solution. Microscopy at a magnification of 250-400 times. If necessary, phase contrast microscopy (produces more plastic images).

Mycological culture: culture from vaginal secretion. Subcultures on rice agar are required to determine the species of fungus in order to assess the chlamydospore formation of C. albicans. Candida glabrata does not form true mycelia or pseudomycetes.

Germination tube test.

Gonorrhoea

Trichomonas colpitis

Bacterial vaginosis and vaginitis

Vulvovaginitis with detection of A-streptococci

Vulvodynia

genital herpes

lichen sclerosus et atrophicus

lichen planus mucosae

With a consequent local therapy every vaginal mycosis can be cured.

The high recurrence rate is problematic. In about 10% of women, regular recurrences occur despite sufficient therapy. The co-treatment of the partner is essential, see below. Balanitis candidamycetica.

Cave! Partner may be a carrier even without clinical symptoms.

Possibly treatment of an underlying disease.

Control of the stool flora, exclusion or therapy of intestinal candidosis.

Antiseptic measures (rinsing or compresses) with octenidine.

2 times/day local therapy with topical antimycotics, e.g. Ciclopirox (e.g. Batrafen cream), Bifonazol (e.g. Mycospor cream) or Clotrimazol (e.g. Canesten).

The use of vaginal tablets or suppositories is also necessary. Vaginal tablets or ovules are to be inserted deep into the vagina for 1, 3 or 6 consecutive days (depending on the pharmacon).

• Ciclopirox (e.g. inimur myco vaginal suppositories): 1 vaginal suppository must be inserted once a day (in the evening). Alternatively, Batrafen vaginal cream can be applied once a day in the evening for 6 days using a disposable applicator.
• Clotrimazole (e.g. Antifungol Hexal vaginal tablets): 1 time a day, in the evening, 1 vaginal blob for 3 consecutive days.
• Nystatin (e.g. Adiclair vaginal tablets): In the evening, before going to bed, take 1-2 vaginal tablets deep intravaginally. Use for 3 days, 6 days if necessary.

• In recurrent candidosis with C. albicans, a one-day oral therapy with itraconazole preparations(e.g. Siros 2 times/day 200 mg p.o. for 1 day) or fluconazole (e.g. Diflucan®) once 150 mg p.o. can be successful.
• Candida glabrata and Candida krusei are only slightly sensitive to azole antifungals! Therefore, in the case of chronic vaginal complaints caused by C. glabrata, at least 2-3 weeks therapy with fluconazole of at least 750 mg/day is indicated.
• For Candida krusei vaginitis local therapy is usually sufficient.
• In severe cases or if the course of a C. glabrata or C. krusei infection is resistant to therapy, posaconazole can be tried: 400 mg (10 ml) p.o. 2 times/day (daily dose 800 mg) or 4 times/day 200 mg (5 ml) p.o. for 10-14 days.
• In severe cases or if the course of a C. glabrata or C. krusei infection is resistant to therapy, voriconazole can be used alternatively. Adults and children > 12 years. Initially on 1st day of treatment 400 mg p.o. In patients with < 40 kg bw 200 mg p.o. every 12 hours Maintenance dose from 2nd day of treatment: 2 times/day 200 mg p.o. (patient > 40 kg KG) or 2 times/day 100 mg p.o. (Pat. < 40 kg KG). Duration of therapy 3 days.
• If necessary, treatment of an underlying intestinal candidosis, see below Candidosis, enteral.

Notice! In case of excessive colonisation of the intestine (> 104 Kb/g stool) oral treatment with Nystatin.

• No washcloths (or disposable washcloths) due to risk of contamination.
• Change underwear and towels every day and cook (for at least 5-10 minutes).
• No tampons (occluding effect!).
• Careful genital cleaning to avoid contamination of the vulva with stool.
• No underwear that is too tight.
• Build up the physiological flora, e.g. with Lactobacillus acidophilus (e.g. Vagiflor).

• Remove material without prior disinfection, in case of discharge by means of an eyelet, but also directly from the speculum on a slide or fungal agar.
• Cover a few drops of specimen material on a microscope slide with a cover glass and, unstained and at medium magnification, examine the specimen for fungal threads and shoot cells.
• For staining, one drop of saturated alcoholic methylene blue solution can be added to the material on the slide. Staining time 30 sec.
• Inoculate fungal agar with plenty of material and incubate at room temperature. Yeasts usually grow after 2-3 days, moulds may take a little longer. Dermatophytes do not cause vaginal mycosis.
• Spread a little of the primary culture on rice extract agar very thin in serpentine or straight lines, cover with cover glass and (very important!) incubate at room temperature for 1-2 days. Do not incubate at 37 °C!
• Candida albicans can be recognized by the typical chlamydospores formed on rice agar. The differentiation of the other yeasts requires physiological examination, e.g. by fermentation of different sugars and organic and inorganic nitrogen.

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