Vulvovaginal Candidiasis

Vaginal candidiasis is commonly referred to as ‘thrush’; it refers to vaginal infection with a yeast of the Candida family

Aetiology

Causative Organisms

  • Candida albicans (≈80–90%)
  • Non-albicans species:
    • Candida glabrata
    • Candida tropicalis
    • Candida krusei

Mycological Features

  • Yeast-like fungi
  • Normal commensals of the vagina, GI tract, and skin
  • Dimorphism (yeast and pseudohyphal forms)
  • Overgrowth occurs when host–microbial balance is disturbed

Risk factors

  • Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
  • Poorly controlled diabetes
  • Immunosuppression (e.g. using corticosteroids)
  • Broad-spectrum antibiotics

Pathophysiology

  1. Disruption of normal vaginal flora
  1. Overgrowth of Candida species
  1. Adherence to vaginal epithelium
  1. Hyphal transformation and invasion
  1. Intense inflammatory response
Key principle:
VVC is highly inflammatory, unlike BV.

Clinical presentation

Symptoms
  • Severe vulvovaginal pruritus (hallmark)
  • Burning sensation
  • Dysuria (external)
  • Dyspareunia
  • Thick, white, curdy (“cottage cheese”) discharge
  • Typically no foul odor
Signs
  • Vulvar erythema and edema
  • Excoriations or fissures
  • Vaginal mucosa appears inflamed
  • Adherent white plaques (may bleed on removal)

Investigations

Clinical Clues

  • Intense pruritus
  • Normal vaginal pH (≤4.5)

Microscopy

  • 10% KOH wet mount
  • Budding yeast cells (blastospora)
  • Pseudohyphae (suggests C. albicans)

Culture

  • Indicated in:
    • Recurrent or complicated VVC
    • Suspected non-albicans species

NAATs

  • Increasingly used
  • High sensitivity

Management

  • Clotriomazole 500mg SD intravaginal
  • Clotrimazole 200mg intravaginal for 3 days
  • Nystatin 100.000 IU intravaginal for 7 days
  • Fluconazole 150mg SD PO
  • Itraconazole 200mg BID PO for 1 days
  • Itraconazole 100mg PO for 3 days
  • Ketoconazole 200mg BID PO for 5 days