Discussing vulvovaginal physiology and diagnosis and management of fungal infection

1. Fungal Vulvovaginal Infection
Dr. Mamdouh Sabry
MD. Ain Shams, PhD. France
Consultant Ob. & Gyn.
EL Mataria Teaching Hospital, Nasser Institute
Cairo, Egypt

2. Vaginal Environment
• The vagina is a dynamic system that contains
approximately 109 bacterial colony-forming units.
And can do self reform in healthy females.
• Normal vaginal discharge is clear to white,
odorous or odorless and of high viscosity.
• Normal bacterial flora is dominated by lactobacilli
– other potential pathogens present.
• Acidic environment (pH 3.8-4.2) inhibits the
overgrowth of bacteria
• Some lactobacilli also produce H2O2, it is a
potential microbicide

3. Physiologic secretions
• Transudate from vaginal wall
-St. sq. epithelium.
-Polymorphs and leucocytes
-Bacterial flora.
• Genital tract secretions
-F. tube, endometrium and cervix.
-Vulva ( skene,s tubules, Bartholin gland
and seb. glands )

4. Defensive Mechanism
• Vulva :
- H shape closing.
- Fungicide gland secretions.
• Vagina:
- Cone shape - Closed introitus
-Vaginal flora - Acidity
- Epithelium St. sq. epithelium.
• Cervix :
• - Bactericide sec. - Immunoglobulins A, G, M.

5. Factors Favoring Infection
- Age extremes .
- Pregnancy.
- Post-natal ( trauma, contamination )
- IUD, combined pills.
- Antibiotics.
- Immunosuppressive drugs or steroids.
- D. M. uncontrolled.

6.  Diabetic patients have higher risk of infection due
to many factors;
Hyperglycemia and acidemia that exacerbate
impairments in humoral immunity, polymorphs and
lymphocyte functions, ↓ random motion of
neutrophils, chemotaxis, phogocystosis and
microbial killing mechanisms.
Glucose levels in genital tissues enhance yeast
adhesion and growth.
Long standing D.M causes vasclopathy with poor
tissue perfusion.
Diabetic neuropathy results in delay response.

7. Vaginitis
• Inflammation and irritation of the vagina
and vulva.
---Infections: ---No infections:
-Bacterial vaginosis -Atrophic
-Fungal, VVC. -Traumatic
-Parasitic, T.V. -Chemical
-Viral, HSV, HPV. -Adenosis, VIN.
Increase liability to inf.

8. 8
Vulvovaginal Candidiasis
• Fungal infection caused by candida albicans or non albicans
group, affects most females during lifetime. More common in
women at reproductive age.
• The second most common cause of vaginitis, 35 – 40% ???
• 75% of all women experienced at least one episode of VVC
during life time.
• 40 – 50% will suffer multiple attacks or episodes of VVC.
• Around 5-8% experienced chronic VVC.
• It is not a life threatening rather than a life disturbing disease,
affecting quality of life.

9. Microbiology
• Candida species are normal flora of the skin and
vagina
• VVC is caused by overgrowth of C. albicans and
other non-albicans species
• Yeast grows as oval budding yeast cells or as a
chain of cells (pseudohyphae)
• Symptomatic clinical infection occurs with
excessive growth of yeast
• Disruption of normal vaginal ecology or host
immunity can predispose to vaginal yeast
infections

10. Presentation and Symptoms
• Vulvar pruritus is most common symptom
• Thick, white, curdy vaginal discharge
("cottage cheese-like")
• Erythema, irritation, occasional
erythematous "satellite" lesion
• External dysuria and dyspareunia
• Cervix appears normal

11. Diagnosis
• History, symptoms and signs.
• Observing pseudohyphae and/or budding yeast
(candida) on KOH, Gram stain or saline wet prep (
Whiff test )
• pH > 4.5 (84-97% sensitive, 57-78% specific)
• Cultures not used for routine diagnosis, important in
non albicans resistant infection with Nickerson or
Sabourad media
• Pap smear have high (false +ve, -ve results )
• Latex agglutination test for candida sp. .

12. Classification of VVC
Uncomplicated VVC
– Sporadic or infrequent
vulvovaginal candidiasis
Or
– Mild-to-moderate
vulvovaginal candidiasis
Or
– Likely to be C. albicans
Or
– Non-immunocompromised
women
Complicated VVC
– Recurrent vulvovaginal
candidiasis (RVVC)
Or
– Severe vulvovaginal
candidiasis
Or
– Non-albicans candidiasis
Or
– Women with uncontrolled
diabetes, debilitation, or
immunosuppression or those
who are pregnant

13. Anti Fungals
Local & Oral
1- Local (topical, intravaginal) antifungals:
Polyene: nystatin.
Azoles: clotrimazole, miconazole, econazole,
butoconazole, ticonazole, terconazole.
2- Oral antifungals:
Ketoconazol 200 mgm ???
Floconazol 150 mgm
Itraconazol 100 mgm

14. •Both polyene and azoles are fungistatic rather
than fungicidal.
•Nystatin is less effective than azole treatment.
It needs to be given for 14 days.
•Azoles resulted mostly in higher rates of
clinical & mycologic cure (80-95%) than
nystatin (&0-90%) in non pregnant acute VVC.
•Short course (single dose & regimens of 1-3
days) treats well uncomplicated VVC.
•Combined oral, local and male ttt is advised,
while during pregnancy, no oral ttt ???

15. Uncomplicated VVC
• Mild to moderate signs and symptoms
• Non-recurrent
• 75% of women have at least one
episode
• Responds to short course regimen

16. CDC-Recommended Treatment Regimens
• Intravaginal agents:
– Butoconazole 2% cream, 5 g intravaginally for 3 days†
– Butoconazole 2% sustained release cream, 5 g single intravaginally application
– Clotrimazole 1% cream 5 g intravaginally for 7-14 days†
– Clotrimazole 100 mg vaginal tablet for 7 days
– Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
– Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application
– Miconazole 2% cream 5 g intravaginally for 7 days†
– Miconazole 100 mg vaginal suppository, 1 suppository for 7 days†
– Miconazole 200 mg vaginal suppository, 1 suppository for 3 days†
– Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days
– Tioconazole 6.5% ointment 5 g intravaginally in a single application†
– Terconazole 0.4% cream 5 g intravaginally for 7 days
– Terconazole 0.8% cream 5 g intravaginally for 3 days
– Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
• Oral agent:
– Fluconazole 150 mg oral tablet, 1 tablet in a single dose

17. Complicated VVC
• Recurrent (RVVC)
– Four or more episodes in one year
• Severe
– Edema
– Excoriation/fissure formation
• Non-albicans (Parapsilosis, lambica, glabrata, trop.)
• Immunocompromised host or D.M. uncontrolled
• Pregnancy

18. Complicated VVC Treatment
• Recurrent VVC (RVVC)
– 7-14 days of topical therapy, plus
– 150 mg oral dose of fluconazole repeated 3 days
later 2 times ( days 1,4, 7 )
– Maintenance regimens ( CDC STD treatment
guidelines) weekly or monthly
• Severe VVC
– 7-14 days of topical therapy, plus
– 150 mg oral dose of fluconazole repeated in 72
hours or itraconazol.

19. Partner Management
• VVC is not usually acquired through sexual
intercourse.
• Treatment of sex partners is not recommended
but may be considered in women who have
recurrent infection.
• A minority of male sex partners may have
balanitis and may benefit from treatment with
topical antifungal agents to relieve symptoms.

20. Patient Counseling and Education
• Nature of the disease
– Normal vs. abnormal vaginal discharge,
signs and symptoms of candidiasis
• Transmission Issues
– Not always sexually transmitted
• Risk reduction
– Avoid unnecessary douching, unneeded
antibiotic use, finish course of treatment

21. • May PH ( by litmus paper ) help in
diagnosis of vaginal infection ?
• Yes……

22. • Candidiasis > 4,5
• T. Vaginalis 5-7
• Bacterial vaginosis 5-6

23. • Mixed infection may be diagnosed ?
• If so on which bases ?

24. • Asymptomatic fungal infection may be
treated or not ?

25. • Vaginal application of antimicrobials and
antiseptic agents with broad bactericide
and fungicide activity or cleansers may be
effective ?
• Effectiveness of human lactobacillus
strains as vaginal supp. ?

26. • Adjuvant ttt in mixed infection.
• Eradicate secretions prior to ttt starting.
• They decrease risk of resistance if not
sure of diagnosis.
• May be used as pre-ttt at ovulation time.
• Lactobacillus supp. may be helpful in
some situations…

27. • Butoconazol and other azoles better given
on single application or 3 days course and
why ?
• Butoconazol or other azoles in acute
attacks in diabetics and immune-affected
patients may be given more than 3 days
course ?