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Candidal Vaginitis

By

Oluwatosin Goje

, MD, MSCR, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University

Last full review/revision Apr 2021| Content last modified Apr 2021

Candidal vaginitis is vaginal infection with Candida species, usually C. albicans.

(See also Overview of Vaginitis.)

Most fungal vaginitis is caused by C. albicans (candidiasis), which colonizes 15 to 20% of nonpregnant and 20 to 40% of pregnant women.

Risk factors for candidal vaginitis include the following:

  • Diabetes
  • Use of a broad-spectrum antibiotic or corticosteroids
  • Pregnancy
  • Constrictive nonporous undergarments
  • Immunocompromise
  • Use of an intrauterine device

Candidal vaginitis is uncommon among postmenopausal women except among those taking systemic hormone therapy.

Symptoms and Signs of Candidal Vaginitis

Vaginal vulvar pruritus, burning, or irritation (which may be worse during intercourse) and dyspareunia are common, as is a thick, white, cottage cheese–like vaginal discharge that adheres to the vaginal walls. Symptoms and signs increase the week before menses. Erythema, edema, and excoriation are common.

Women with vulvovaginal candidiasis may have no discharge, a scanty white discharge, or the typical cottage cheese–like discharge.

Infection in male sex partners is rare.

Recurrences after treatment are uncommon.

Diagnosis of Candidal Vaginitis

  • Vaginal pH and wet mount

Criteria for diagnosing candidal vaginitis include

  • Typical discharge (a thick, white, cottage cheese–like vaginal discharge)
  • Vaginal pH is < 4.5
  • Budding yeast, pseudohyphae, or mycelia visible on a wet mount, especially with potassium hydroxide (KOH)

If symptoms suggest candidal vaginitis but signs (including vulvar irritation) are absent and microscopy does not detect fungal elements, fungal culture is done. Women with frequent recurrences require culture to confirm the diagnosis and to rule out non-albicans Candida.

Also, some relatively new diagnostic tests are commercially available for clinical use (1).

Diagnosis reference

  • 1. Schwebke JR, Gaydos CA, Nyirjesy P, et al: Diagnostic performance of a molecular test versus clinician assessment of vaginitis. J Clin Microbiol 56 (6):e00252-18, 2018. doi: 10.1128/JCM.00252-18 Print 2018 Jun.

Treatment of Candidal Vaginitis

  • Antifungal drugs (oral fluconazole in a single dose preferred)
  • Avoidance of excess moisture accumulation

Keeping the vulva clean and wearing loose, absorbent cotton clothing that allows air to circulate can reduce vulvar moisture and fungal growth.

Topical or oral drugs are highly effective for candidal vaginitis (see table Drugs for Candidal Vaginitis). Adherence to treatment is better when a one-dose oral regimen of fluconazole 150 mg is used. Topical butoconazole, clotrimazole, miconazole, and tioconazole are available over the counter. However, patients should be warned that topical creams and ointments containing mineral oil or vegetable oil weaken latex-based condoms.

If symptoms persist or worsen during topical therapy, hypersensitivity to topical antifungals should be considered.

Some Drugs for Candidal Vaginitis

Drug

Dosage

Topical or vaginal

Butoconazole

Sustained-release preparation of 2% cream

5 g as a single application

Clotrimazole

1% cream 5 g once a day for 7 to 14 days or 2% cream 5 g for 3 days

Miconazole

2% cream 5 g once a day for 7 days or 4% cream 5 g for 3 days

Vaginal suppository 100 mg once a day for 7 days or 200 mg once a day for 3 days or 1200 mg, only once

Terconazole

0.4% cream 5 g once a day for 7 days or 0.8% cream 5 g once a day for 3 days

Vaginal suppository 80 mg once a day for 3 days

Tioconazole

6.5% ointment 5 g once

Oral

Fluconazole

150 mg in a single dose

Frequent recurrences require long-term suppression with oral drugs (fluconazole 150 mg weekly to monthly or ketoconazole 100 mg once a day for 6 months). Suppression is effective only while the drugs are being taken. These drugs may be contraindicated in patients with liver disorders. Patients taking ketoconazole should be monitored periodically with liver function tests.

Drugs Mentioned In This Article

Drug Name Select Trade
ketoconazole NIZORAL
clotrimazole MYCELEX
butoconazole FEMSTAT 3
tioconazole VAGISTAT-1
fluconazole DIFLUCAN
Terconazole TERAZOL 3
miconazole MONISTAT 3

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