Assessment of vulvovaginitis caused by Candida and related species in adults
Vulvovaginitis is an inflammation or irritation of the vagina and vulva. In adults presenting with vulvovaginitis, obtain a clinical history and examine the genital area to determine the likely cause. Candida and related species are some of the most common causes of vulvovaginitis in adults.
‘Candida’ may be used as a descriptive term as well as a genus name. Some yeasts that were previously considered Candida species have been reclassified and are now considered candida-like and may be reported with a new name (eg Nakaseomyces glabratus, Pichia kudriavzevii)Borman, 2021Keighley, 2021. For a list of commonly encountered Candida and related species and, if applicable, revised species names, see Common Candida and related species, and changes to nomenclature1.
Vulvovaginitis caused by Candida and related species presents as genital or vulval itch or discomfort, sometimes with pain, and often with a red rash on the vulva. It is often accompanied by white curd-like vaginal discharge (although discharge can also appear normal). Superficial dyspareunia, external dysuria, excoriation, fissuring, erythema and swelling may also be presentOng, 2023Saxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad, , 2020. Vulvovaginitis caused by Candida and related species may be associated with broad-spectrum antibiotic use, third trimester of pregnancy and diabetes mellitus.
Most cases are isolated or infrequent episodes resulting from sporadic increases in Candida and related species in the vagina. However, recurrent acute vulvovaginitis and chronic vulvovaginitis caused by Candida and related species can also occur. Vulvovaginitis caused by Candida and related species is uncommon in postmenopausal patients, but may be related to the use of hormone replacement therapy (HRT), see Management of postmenopausal chronic vulvovaginitis caused by Candida and related species.
If vulvovaginitis caused by Candida and related species is suspected, it is good practice to take a high vaginal swab for microscopy and culture to confirm the diagnosis and start treatment while waiting for results. The patient may self-collect2, if able. Culture may be useful to identify the specific pathogen in severe vulvovaginitis (eg extensive vulval erythema, oedema, excoriation and fissuring on external examination) or recurrent vulvovaginitis.
If microscopy and culture is performed, consider the following:
- Colonisation with Candida and related species is common and treatment is not required unless there are symptoms of vulvovaginitis. If yeasts or pseudohyphae with white cells are absent on vaginal microscopy and culture, consider an alternative diagnosis.
- Candida albicans is the main species associated with infection, but less common related species (most often Nakaseomyces glabratus [formerly known as Candida glabrata] and Pichia kudriavzevii [formerly known as Candida krusei]) are isolated in 10% of patientsSaxon, Edwards, Rautemaa-Richardson, Owen, Nathan, Palmer, Wood, Ahmed, Ahmad, , 2020.
- Results from a swab taken after imidazole or nystatin treatment may be falsely negative for some time, even though the patient still has symptoms. Use of empirical over-the-counter imidazole or nystatin treatment complicates assessment in primary care.
In adults with vulvovaginitis, also consider other diagnoses, such as:
- bacterial vaginosis, a common cause of vulvovaginitis in adults that causes an offensive smelling discharge
- the presence of a retained foreign body (eg toilet tissue, tampon, condom), particularly in cases that are persistent, severe or present with bloody discharge
- irritation (eg from over washing, use of perfumed soaps, wipes or feminine hygiene products)
- dermatoses (eg dermatitis, lichen sclerosus, psoriasis)
- atrophic vaginitis
- Trichomonas vaginalis.
Increased cervical mucus production is a common cause of vaginal discharge, particularly in patients taking oral contraceptives. This does not require treatment.