History and Physical Examination
Vulvovaginal candidiasis
Acute vulvovaginal candidiasis
In acute vulvovaginal candidiasis, vulvar pruritus and burning are the main symptoms. Patients commonly complain of both symptoms after intercourse or upon urination. Dyspareunia may develop and become severe enough to lead to intolerance of intercourse.
Physical findings include erythema and edema of the vestibule and of the labia majora and minora. The rash may extend to the thighs and perineum. Thrush patches are usually found loosely adherent to the vulva. A thick, white, curdlike vaginal discharge is usually present. [21, 22, 23, 24]
Chronic vulvovaginal candidiasis
The clinical picture of chronic, persistent vulvovaginal candidiasis differs in that it includes marked edema and lichenification of the vulva with poorly defined margins. Often, a grayish sheen made up of epithelial cells and organism covers the area. Symptoms include severe pruritus, burning, irritation, and pain. Patients with chronic candidiasis are usually older and obese and often have long-standing diabetes mellitus. [25]
Atrophic vaginitis
Most women with mild to moderate vaginal atrophy (60-90%) are asymptomatic or have symptoms that cause no distress. Clinical symptoms include the following:
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Vaginal soreness
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Postcoital burning
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Dyspareunia
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Burning leukorrhea
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Occasional spotting
Pronounced symptoms of atrophic vaginitis generally appear only after estrogen levels have been low for an extended period of time.
Early on, women may notice a slight decrease in vaginal lubrication upon arousal, which is one of the first signs of estrogen insufficiency. As the hypoestrogenic state becomes chronic, additional symptoms arise. The most common symptom is vaginal spotting, which usually results from a break in the thin vaginal mucosa. Dyspareunia may result from ulceration of the vulvovaginal epithelium.
The vagina is noted to be thin, with occasional petechia and diffuse redness and with few or no vaginal folds. A serosanguineous discharge may be present, with a pH of 5-7. A wet mount often shows white blood cells and a paucity of Lactobacillus.
Vulvar vestibulitis
Women who are first affected are usually young, sexually active, and of Caucasian origin. Most patients have endured their symptoms for several months and have empirically tried various remedies with no improvement.
Vulvar vestibulitis can be divided into primary and secondary forms, as follows:
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Primary vulvar vestibulitis (20% of cases) - Introital dyspareunia that starts from initiation of sexual activity or intolerable pain consistently present upon insertion of a tampon or vaginal speculum in women who have never been sexually active
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Secondary vulvar vestibulitis - Introital dyspareunia that develops after a period of comfortable sexual relations, tampon use, or speculum examinations
Usual symptoms include pain, soreness, burning, and a feeling of rawness that is aggravated by stress, exercise, tight clothing, coitus, and tampon use. The pain is usually not considered constant but is elicited by any attempt to enter the vagina.
Many patients complain of an irritating vaginal discharge and a vulvar burning sensation. Examination may reveal small spots of erythema around the vestibular glands, with rare ulceration. Lesions are predominantly found in the lower portion of the vestibule. [26]
Unfortunately, standard pelvic examination typically reveals no physical findings. Gentle pressure with a cotton-tipped applicator around the base of the hymenal ring and posterior fourchette usually elicits the pain.
Contact dermatitis
The diagnosis usually is based on the patient's history and physical examination. Clinical symptoms consist of varying degrees of tenderness, pain, burning, and pruritus. Urinary retention may occur in severe cases.
Pruritus is the cardinal symptom. However, an acute reaction may develop as a result of exposure to a potent irritant that involves the mucosa, leading to burning, rawness, and pain. This initially presents as red and edematous skin followed by exudation and weeping, which may lead to secondary infections. The irritant also may be potent enough to cause erosion, ulceration, or necrosis.
Repetitive exposure to weak irritants with an insufficient period of healing and restoration of skin integrity between each exposure characterizes chronic contact dermatitis. Contact dermatitis of long duration may include lichenification, scaling, thickening of the skin, and white plaques.
When the mechanism is an allergen, the symptoms may not be apparent until 24-48 hours after contact, while an irritant will elicit immediate symptoms.
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Candida albicans photomicrograph. Courtesy of Centers for Disease Control and Prevention (CDC).
Tables
Option |
Treatment |
Butoconazole |
2% cream, 5 g intravaginally for 3 days |
Butoconazole |
2% cream, 5 g (butoconazole 1-sustained release), single intravaginal 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 |
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 |
Miconazole |
1200 mg vaginal suppository, 1 suppository for 1 day |
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 |
Fluconazole |
150 mg oral tablet, 1 tablet in single dose |
| Ibrexafungerp | 150 mg oral tablet, 2 tablets (300 mg) BID x 2 doses |
