Definition
Vulvovaginal candidiasis (genital thrush): symptomatic inflammation of the vagina and/or vulva secondary to fungal infection.
Recurrent infection: ≥4 symptomatic episodes in 1 year, at least 2 confirmed by microscopy / culture (at least one by culture)
Aetiology
Most common caused by Candida yeasts
- Most common species: Candida albicans (80-89% cases)
- Candida glabrata (5%)
Risk Factors
- Local irritants – douching, soaps, shampoos, shower gels
- Recent antibiotic use (within 3 months)
- Immunosuppression
- Poorly controlled diabetes mellitus
- HIV infection
- Long-term corticosteroid use
- Oestrogen exposure
- Pregnancy
- COCPCombined oral contraceptive pill
- HRTHormone replacement therapy
Clinical Features
Possible symptoms:
- Vulval / vaginal itching (most common), soreness and irritation
- Superficial dyspareunia
Superficial dyspareunia is pain experienced at the vaginal introitus or vulvar vestibule during initial penetration or entry. It is typically seen in conditions such as vaginal atrophy (including genitourinary syndrome of menopause) and infections such as candidiasis or herpes simplex (which are superficial in nature).
Deep dyspareunia on the other hand is pain felt deep within the vagina, pelvis, or lower abdomen during deep penetration. It is most commonly associated with endometriosis, pelvic inflammatory disease, pelvic masses and other structural or anatomic abnormalities.
and dysuria
On examination:
- White ‘cheese-like’ discharge (non-malodorous)
- Erythema
- Vaginal fissuring and/or oedema
- Excoriations
- Satellite lesionsSatellite lesions in the context of vaginal candidiasis are small pustulopapular or erythematous lesions that appear adjacent to the main area of vulvovaginal inflammation, typically on the labia or perineal skin.
However, their presence is not highly specific, and they may also be seen in other cutaneous fungal infections, such as candidal intertrigo, and rarely in other conditions (i.e., other fungal infections)
(often associated with more severe/extensive disease)
Investigation and Diagnosis
Clinical diagnosis is usually sufficient in the presence of typical signs and symptoms
Consider the following for recurrent infection / diagnostic uncertainty:
| High vaginal swab for microscopy |
|
| Vaginal pH testing of secretions |
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| Midstream sample of urine |
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| HbA1c |
|
Management
Acute Infection
Choice of anti-fungal (both oral and topical treatment gives similar cure rates):
- 1st line: oral fluconazole (single dose)
- 2nd line: topical therapies
- Preferred: intravaginal clotrimazole pessary (single dose)
- Alternative: intravaginal antifungal creams (i.e, clotrimazole or miconazole)
Treatment Failure
Definition: if no response to initial treatment within 7-14 days
- Perform a high vaginal swab
- Treat according to high vaginal swab results
Partner Management
| Asymptomatic partner | Contact tracing / treatment is NOT indicated |
| Symptomatic male partner | Suspected / confirmed candidal balanitis [Ref]
|
Recurrent Infection
Offer an induction-maintenance regimen:
- Induction: 3 doses of oral fluconazole – to be taken every 72 hours
- Maintenance: oral fluconazole once a week for 6 months
2nd line induction-maintenance regimen:
- Induction: topical clotrimazole intravaginal pessary up to 7-14 days
- Maintenance: topical clotrimazole intravaginal pessary once a week for 6 months OR oral itraconazole daily for 6 months
Infection During Pregnancy
Duration of treatment is 7 days (applied at night):
- 1st line: topical clotrimazole intravaginal pessary
- 2nd line: intravaginal anti-fungal creams (i.e, clotrimazole or miconazole)
Pregnant women generally need a longer duration of treatment (for 7 days) to clear the infection, as opposed to the single-dose treatment preferred in non-pregnant women.
Oral antifungals (including fluconazole) are generally contraindicated in pregnancy.
Topical antifungals are safe alternatives in pregnancy, as there is limited systemic absorption from the vagina.
References
NICE CKS Candida - female genital
BASHH Vulvovaginal Candidiasis 2019