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    Recurrent vulvovaginitis: Tips for treating a common condition

     

    Candidiasis

    Vulvovaginal candidiasis is a common infection, affecting the majority of women at least once during their reproductive years, and more than 50% of women experience at least 2 infections.17 Up to 8% of women will experience recurrent vulvovaginal candidiasis, defined as 4 or more episodes per year. Many women self-treat and misdiagnose, making exact prevalences difficult to ascertain.

    The primary symptom is vulvar pruritus but burning, soreness, and irritation also are common. Women will often present with edema, fissures, and excoriations from scratching. They may complain of burning with urination or dyspareunia. The classic discharge is thick, white, and clumpy.18 The primary culprit is Candida albicans, found in up to 90% of all cases. Any of the more than 100 species of C. albicans can cause the same symptoms. Candida glabrata is the most prevalent non-albicans species encountered and is not amenable to treatment with common vaginal and oral therapies used for Candida.19

    Diagnosis

    The diagnosis of yeast is done with a microscopic evaluation of vaginal secretions. Hyphae or spores are often visible in normal saline or 10% KOH. A culture should be sent if the diagnosis is in question or if there are persistent or recurrent symptoms. This will confirm the presence of yeast and identify the strain for better clinical treatment. The vaginal pH may be lower than 4.5 but this is not always consistent.20

    Yeast should be high on the differential in women with certain risk factors. Recent antibiotic use, diabetes, increased estrogen, immunosuppression, and coitarche have all been linked to an increase in infection.21

    Many women are asymptomatic carriers of yeast; therefore, treatment should be focused on those experiencing symptoms. It is important to confirm the presence of yeast before initiating treatment as many women with vulvar pruritus will have a diagnosis other than yeast. The self-diagnosis of yeast should be discouraged, especially with recurrent infections and infections not linked to a known trigger because women tend to be wrong a significant amount of the time.18

     

    Merida Miller, MD
    Dr. Miller is Associate Professor of Obstetrics and Gynecology, University of Iowa, Iowa City.

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    • Dr. Neil S. Gladstone
      I appreciated Dr. Miller's discussion of a common and vexing problems for both patients and clinicians. For 45 years, I have seen more unhappy patients with BV than any other condition including malignancies. At least with cancer, there is hope of a cure. With BV it never goes away. The two most important tools for the clinician in diagnosis BV are pH paper and a microscope. After the history, which is predictable, and after my vaginal exam. I do a pH on the discharge taken from the upper aspects of the vagina. The pH helps to direct what comes next. If the pH is in the acidic range the differential diagnosis is either Candida (yeast) or leucorrhea. If the patient presents with a history suggestive of yeast and she has a "Typical" cottage cheese discharge, and we are not dealing with multiple recurrences, I elect to treat with either topical or oral agents. For problem cases I will use a NAAT testing procedure. If the pH is in the alkaline range, I do a wet smear. If there is no evidence of Trichomands and with presence of Clue Cells, I make the diagnosis of BV. My treatment is two fold: I take the time needed to explain to the patient what are the triggers for BV, that the bacteria that cause the BV symptoms are residents of the vagina and can not be totally eliminated, and the change in pH temporarily eliminates the beneficial action of Lactobacillus. In this environment it is the anaerobes that were listed in the article that predominate. I encourage all patients to use condoms at all times and to use tampons to get rid of menstrual blood as quickly as possible. Instead of continually prescribing Metronidazole or Clindamycin orally, I use Boric acid vaginal suppositories 600 mg for at least one week. Patients do not like the topical antibiotics as the perception these measures do not work. They are unhappy because the oral antibiotics do not work because the "infection" keeps reoccurring, I never reference BV as a STI,but I also talk about keeping the environment of the vagina healthy by keeping out the offending substances and restoring the pH. The suppositories help with Candida as well. One part of therapy most clinicians especially non OBGYNS fail to do is to use a steroid and antifungal topical combination for the skin of the vulva. This maneuver provides relief for the irritated itchy skin. Each patient gets a written information about BV and I always offer to discuss the diagnosis with reluctant partners. This approach is not the panacea for BV , but I think it is more successful than the manner most people treat BV.This is anecdotal information, but I think it would merit someone with the time and patients to do a RCT. Also, I am very liberal in ordering STI panels including the use of NAAT panels. Neil S Gladstone, MD, FACOG,CCD

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