Vulvovaginal Candidiasis (Yeast Infection)

Obstetrics & Gynecology

Description

Vulvovaginal candidiasis is an over-growth of Candida yeasts—classically Candida albicans but increasingly C. glabrata and other non-albicans species—in the vagina and vulva. The organisms, which are normal commensals in up to 30 % of asymptomatic individuals, proliferate when local or systemic host defenses are perturbed, producing an inflammatory vaginitis characterized by itching, burning, and curdy discharge. By age 50, roughly 70 – 75 % of women experience at least one symptomatic episode, and 5 – 8 % develop the chronic, “recurrent” form defined by four or more episodes in a year.

Symptoms

Hallmarks are intense vulvar pruritus, burning, soreness, and external dysuria. Examination reveals vulvar erythema, edema, fissures, and adherent thick “cottage-cheese” discharge without strong odor. Dyspareunia and labial excoriations are common. Fever, pelvic pain, or foul, thin, fishy discharge suggest an alternative or concomitant diagnosis.

Risk Factors

Recent broad-spectrum antibiotics, combined oral contraceptives or hormone-replacement therapy, pregnancy, poorly controlled diabetes, high-dose corticosteroids, HIV infection or other immunodeficiency, tight occlusive clothing, repeated intravaginal douching, high-sugar diets, and genetic polymorphisms in the DECTIN-1 and CARD9 innate-immunity pathways heighten susceptibility. Long-term SGLT2-inhibitor therapy and frequent sexual intercourse with lubricants that raise vaginal pH are emerging contributors.

Diagnosis

Diagnosis is confirmed, not presumed. Office microscopy of vaginal discharge mixed with 10 % KOH demonstrates budding yeasts or pseudohyphae. Vaginal pH remains ≤ 4.5, distinguishing candidiasis from bacterial vaginosis and trichomoniasis. In recurrent, complicated, or non-responsive cases, a fungal culture or PCR that identifies species and antifungal susceptibility is essential. Routine empiric treatment without testing risks missing mimics such as Desquamative inflammatory vaginitis or HSV-related vulvitis.

Treatment

Uncomplicated (sporadic, mild-to-moderate, C. albicans)—Any single-dose oral fluconazole 150 mg or a short vaginal azole (e.g., miconazole 2 % cream 5 g nightly × 7 days) is > 90 % curative. Complicated (severe symptoms, pregnancy, immunosuppression, or non-albicans species)—Use extended azole courses: fluconazole 150 mg on days 1, 4, and 7, or topical azole for 10–14 days. In pregnancy, topical azoles for 7 days are preferred; oral fluconazole is avoided. Recurrent disease—Induction with fluconazole 150 mg every 72 h for three doses, followed by maintenance 150 mg weekly for 6 months reduces recurrences by ~90 %. Alternatives for azole-resistant C. glabrata include boric-acid vaginal capsules 600 mg nightly for 14 days or topical nystatin.

Outlook

Symptom relief occurs within 24–48 h of therapy for most uncomplicated infections. Recurrence after appropriate treatment is ≤ 10 % at 3 months but rises to > 50 % in predisposed hosts if risk factors persist. Early, species-directed therapy and a six-month suppression regimen lead to prolonged remission in two-thirds of women with recurrent disease.

Complications

Severe vulvar edema causing urinary retention, candidal fissures facilitating secondary bacterial cellulitis, psychological distress from chronic pruritus, vulvodynia from repeated inflammation, and azole-resistant Candida selection with indiscriminate OTC use.

Prevention

Minimise unnecessary systemic antibiotics; optimise glycemic control; limit daily added sugars; consider weekly fluconazole prophylaxis for six months after induction in genuine recurrent VVC; probiotically-fortified yogurts or Lactobacillus vaginal suppositories show inconsistent benefit and are not routinely recommended.

Support

Complete full antifungal regimen even after symptoms abate, wear breathable cotton underwear, avoid douching and scented hygienic products, change out of wet exercise clothing promptly, and use non-glycogen-based water-lubricant during intercourse. Partners rarely need treatment unless balanitis or symptoms develop. Keep blood glucose optimally controlled; discuss alternative contraception if estrogen therapy triggers recurrences.