The symptoms are recited every day in gynecologists’ offices around the world: itching, irritation, burning, rawness, pain, dyspareunia. The challenge is tracing these general symptoms to a specific pathology, a task harder than one might expect, because vulvovaginal conditions often represent a complex mix of several problems. Candida and bacterial invasion frequently complicate genital dermatologic conditions. Atrophy and loss of the epithelial barrier worsen the problem. Over-the-counter (OTC) and prescription remedies can lead to contact dermatitis. Vulvodynia may be the ultimate outcome, possibly from central sensitization after chronic inflammation, which in turn can mislead the clinician into thinking appropriate therapy “doesn’t work.” And it is important to remember that any genital complaint has the potential to dampen a woman’s self-esteem and hamper sexual function.
This article covers the fine points of diagnosis and treatment of 4 common vulvovaginal problems:
- Contact dermatitis
- Lichen sclerosus
Could all 4 problems coexist in 1 patient? They frequently do. As always, a careful history and physical examination with appropriate use of yeast cultures make it possible to manage the complexity.
1. CandidiasisTelephone and self-diagnosis are a waste of time
In vulvovaginal candidiasis (VVC), symptoms can range from none to recurrent. VVC can complicate genital dermatologic conditions and interfere with the treatment of illnesses that call for steroids or antibiotics. Because the symptoms of VVC are nonspecific, diagnosis necessitates consideration of a long list of other potential causes, both infectious and noninfectious.
Candida albicans predominates in 85% to 90% of positive vaginal yeast cultures. Non-albicans species such as C glabrata, parapsilosis, krusei, lusitaniae, and tropicalis are more difficult to treat.
Not all episodes are the same
VVC is uncomplicated when it occurs sporadically or infrequently in a woman in good overall health and involves mild to moderate symptoms; albicans species are likely. VVC is complicated when it is severe or recurrent or occurs in a debilitated, unhealthy, or pregnant woman; non-albicans species often are involved. Proper classification is essential to successful treatment.1
Phone diagnosis is usually inaccurate
Although phone diagnosis is unreliable,2 it is still fairly common, and fewer offices use microscopy and vaginal pH to diagnose vaginal infections because of the tightened (though still simple) requirements of the Clinical Laboratory Improvement Amendment. (Clinicians who do wet mounts and KOH are required to pass a simple test each year to continue the practice.)
Women are poor self-diagnosticians when it comes to Candida infection; only one third of a group purchasing OTC antifungals had accurately identified their condition.3
Clinicians are not exempt from error, either. About 50% of the time, Candida is misdiagnosed,4 largely because of the assumption that the wet mount is more specific than it actually is (it is only 40% specific for Candida).
Ask about sex habits, douching, drugs, and diseases
Accurate diagnosis requires a careful history, focusing on risk factors for Candida: a new sexual partner; oral sex; douching; use of antibiotics, steroids, or exogenous estrogen; and uncontrolled diabetes.
Look for signs of vulvar and vaginal erythema, edema, and excoriation.
Classic “cottage cheese” discharge may not be present, and the amount has no correlation with symptom severity.
Vaginal pH of less than 4.5 excludes bacterial vaginosis, trichomoniasis, atrophic vaginitis, desquamative inflammatory vaginitis, and vaginal lichen planus.
Blastospores or pseudohyphae are diagnostic (on 10% KOH microscopy). If they are absent, a yeast culture is essential and will allow speciation. A vaginal culture is especially important in women with recurrent or refractory symptoms.
Always consider testing for sexually transmitted diseases.
Azole antifungals are usual treatment
For uncomplicated VVC, azole antifungals are best (TABLE 1). For complicated VVC, follow this therapy with maintenance fluconazole (150 mg weekly for 6 months), which clears Candida in 90.8% of cases.5
Non-albicans infection can be treated with boric acid capsules (inserted vaginally at bedtime for 14 days) or terconazole cream (7 days) or suppositories (3 days). A culture to confirm cure is essential, since non-albicans infection can be difficult to eradicate.
Note that boric acid is not approved for pregnancy.