Information

15.25A: Vulvovaginal Candidiasis - Biology


Candidal vulvovaginitis is an infection of the vagina’s mucous membranes caused by Candida albicans.

Learning Objectives

  • Analyze the symptoms and factors involved in vulvovaginal candidiasis

Key Points

  • Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes. It is the second most common cause of vaginal inflammation after bacterial vaginosis.
  • The Candida species of fungus is found naturally in the vagina, and is usually harmless.
  • It is not known exactly how changes in the vagina trigger thrush, but it may be due to a hormone (chemical) imbalance. In most cases, the cause of the hormonal changes is unknown. Some possible risk factors have been identified, such as taking antibiotics.

Key Terms

  • Candida albicans: a diploid asexual fungus (a form of yeast). An overgrowth results in candidiasis in immunocompromised patients.
  • vulvovaginal candidiasis: candidal vulvovaginitis or vaginal thrush is an infection of the vagina’s mucous membranes by Candida albicans.

Candidal vulvovaginitis or vaginal thrush is an infection of the vagina’s mucous membranes by Candida albicans. Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes. It is the second most common cause of vaginal inflammation after bacterial vaginosis.

It is most commonly caused by a type of fungus known as Candida albicans. The Candida species of fungus is found naturally in the vagina, and is usually harmless. However, if the conditions in the vagina change, Candida albicans can cause the symptoms of thrush. Symptoms of thrush can also be caused by Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis. Non-albican Candida are commonly found in complicated cases of vaginal thrush such that first line treatment is ineffective. These cases are more likely in immunocompromised patients.

It is not known exactly how changes in the vagina trigger thrush, but it may be due to a hormone (chemical) imbalance. Some possible risk factors have been identified, such as taking antibiotics.

The symptoms of vaginal thrush include vulval itching, vulval soreness and irritation, pain or discomfort during sexual intercourse (superficial dyspareunia), pain or discomfort during urination (dysuria) and vaginal discharge, which is usually odorless. The discharge can be thin and watery, or thick and white, like cottage cheese.

In addition to the above symptoms of thrush, vulvovaginal inflammation can also be present. The signs of vulvovaginal inflammation include erythema (redness) of the vagina and vulva, vagina fissuring (cracked skin), oedema (swelling from a build-up of fluid), also in severe cases, satellite lesions (sores in the surrounding area). This is rare, but may indicate the presence of another fungal condition, or the herpes simplex virus (the virus that causes genital herpes).

While vulvovaginal candidiasis is caused by a the yeast Candida there are many predisposing factors:

  • Infection occurs in about 30% of women who are taking a course of oral antibiotics. The evidence of the effect of oral contraceptives is controversial.
  • In pregnancy, changes in the levels of female sex hormones, such as estrogen, make a woman more likely to develop a yeast infection. During pregnancy, the Candida fungus is more prevalent (common), and recurrent infection is also more likely.
  • Frequency of sexual intercourse appears to be related to the frequency of infections, however infections often occur without sex. Tight-fitting clothing, such as tights and thong underwear, do not appear to increase the risk. Neither do personal hygiene methods.
  • Those with poorly controlled diabetes have increased rates of infection while those with well-controlled diabetes do not.
  • The risk of developing thrush is also increased in a immunodeficiency, for example, by an immunosuppressive condition, such as HIV or AIDS, or receiving chemotherapy. This is because in these circumstances the body’s immune system, which usually fights off infection, is unable to effectively control the spread of the Candida fungus.

Vaginitis: Vulvovaginal Candidiasis

If you’ve had the unpleasant experience of having a vaginal yeast infection you’ll understand when I say that any sharp corner can look appealing!

Yeast infection (vulvovaginal candidiasis) is the most common cause of vulvar irritation and vaginal discharge. Yeast infections are associated with a whitish-coloured, often clumpy discharge, intense itching, inflammation and pain during urination as urine comes in contact with inflamed vulvar tissues. The culprit for most cases of vaginal yeast infections is Candida albicans, although other species of Candida can also cause infection.

Candida albicans is an opportunistic pathogen that responds to opportunities provided to them: antibiotic-treatment, compromised immune systems, birth-control, and vaginal irritation predispose to vaginal infection. Yeast cells are commonly present in low numbers in the vagina: when antibiotics reduce the numbers of bacteria normally residing in the vagina, yeast cells may take the opportunity to attach themselves to vaginal epithelial cells rich in glycogen: yeast love glycogen. Given the opportunity, yeast cells flourish in the glycogen-rich epithelial cells, bud and reproduce resulting in more yeast cells to attach to more vaginal epithelial cells. The symptoms of yeast infection – burning, itching, discharge – are actually an immune response to the metabolic by-products of yeast reproduction. The discharge associated with vaginal yeast infection is not usually outwardly offensive whereas, bacterial vaginosis is often associated with a fishy odor, and Trichomonas infection is often outright offensive!

How is yeast infection diagnosed? Women who have had previous yeast infections have become experts on recognizing a current infection. Unless you have a new sexual partner or have not shared a sexual partner with anyone else (always a possibility), you will likely self-diagnose and purchase an over-the-counter treatment for yeast infection. If, however, you are experiencing symptoms that are new to you or are different in some way than symptoms you have experienced in the past, you should consult your physician. Bacterial vaginosis and Trichomonas vaginalis are also common causes of symptoms of vaginal infection and may present with similar symptoms.

Vulvovaginal candidiasis is diagnosed by the symptoms described above and the presence of yeast cells and pseudohyphae seen microscopically in vaginal discharge, a test often performed in the physician’s office. Alternatively, a sample of vaginal discharge collected from the vagina with a swab is smeared directly onto a glass slide for examination in the laboratory, or placed in a transport media and cultured in the laboratory. The finding of yeast in vaginal smears or cultures without symptoms is not suggestive of infection, as small numbers of yeast may reside normally in the vagina.

Vulvovaginal candidiasis is treated with short-term topical agents such as Clotrimazole, Miconazole or Nystatin inserted intravaginally. Preparations may be preloaded in a tampon-like device increasing ease of use and reducing the mess associated with vaginal creams however, if you choose one of the tampon yeast treatments, you may also want to have some cream on hand to apply to external vulvar tissues to reduce itching, swelling and discomfort.

Numerous natural remedies promise to prevent yeast infections by maintaining or boosting numbers of Lactobacillus, the predominant flora found in the normally acidic environment of the vagina (pH < 4.5): yoghurt and probiotics are two of these. Do probiotics work? There are those who say they do, and those who say they don’t. However, they are generally not harmful, so if they work for you, then they work!


Epidemiological survey of vulvovaginal candidosis in Sfax, Tunisia

Vulvovaginal candidosis (VVC) is a common infection of the female genital tract affecting 75% women at least once in their lifetime. The aim of this study was to determine the incidence and potential risk factors associated with VVC and recurrent vulvovaginal candidosis (RVVC). A prospective study of women with vaginitis symptoms was conducted over 2 years in the regional clinic of population and family education in Sfax. A discriminant analysis was used to evaluate the association between the incidence of Candida vaginitis and potential risk factors. Sporadic and recurrent VVC were documented respectively in 48% and 6.1%. The most frequent factors associated with positive Candida culture were employed women, uncontrolled diabetes, history of genital infection and intrauterine device contraception. Increased episode numbers of VVC and condom/spermicidal contraception were positively associated with recurrences. Candida albicans was the predominantly isolated species (76.3%) followed by Candida glabrata (19.3%). Infection with C. glabrata occurred in 34% and 17.5% of patients with RVVC and VVC respectively. The discriminant investigation had provided further insights into the basis for prevention and control of RVVC. Increased prevalence of C. glabrata in patients with RVVC and observed risk factors should be taken into consideration to achieve success in the management of this infection.


References

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Novel Mechanism behind the Immunopathogenesis of Vulvovaginal Candidiasis: "Neutrophil Anergy"

For over 3 decades, investigators have studied the pathogenesis of vulvovaginal candidiasis (VVC) and recurrent VVC (RVVC) through clinical studies and animal models. While there was considerable consensus that susceptibility was not associated with any apparent deficiencies in adaptive immunity, protective immune mechanisms and the role of innate immunity remained elusive. It was not until an innovative live-challenge design was conducted in women that a fuller understanding of the natural history of infection/disease was achieved. These studies revealed that symptomatic infection is associated with recruitment of polymorphonuclear neutrophils (PMNs) into the vaginal lumen. Subsequent studies in the established mouse model demonstrated that infiltrating PMNs were incapable of reducing the fungal burden, which supported the hypothesis that VVC/RVVC was an immunopathology, whereby Candida and the host response drive symptomatic disease. Further studies in mice revealed the requirement for C. albicans hyphae and identified pattern recognition receptors (PRRs) and proinflammatory mediators responsible for the PMN response, all of which are critical pieces of the immunopathogenesis. However, a mechanism explaining PMN dysfunction at the vaginal mucosa remained an enigma. Ultimately, by employing mouse strains resistant or susceptible to chronic VVC, it was determined that heparan sulfate (HS) in the vaginal environment of susceptible mice serves as a competitive ligand for Mac-1 on PMNs, which effectively renders the PMNs incapable of binding to Candida to initiate killing. Hence, the outcome of symptomatic VVC/RVVC is postulated to be dependent on a PMN-mediated immunopathogenic response involving HS that effectively places the neutrophils in a state of functional anergy.

Keywords: Candida albicans inflammation innate immunity neutrophils vaginitis.

Copyright © 2018 American Society for Microbiology.

Figures

Proposed host-pathogen interactions leading to…

Proposed host-pathogen interactions leading to the immunopathogenic response in mice susceptible to chronic…

Schematic model representing normal PMN…

Schematic model representing normal PMN function in CVVC-resistant mice and the mechanism for…


Epidemiological survey of vulvovaginal candidosis in Sfax, Tunisia

Vulvovaginal candidosis (VVC) is a common infection of the female genital tract affecting 75% women at least once in their lifetime. The aim of this study was to determine the incidence and potential risk factors associated with VVC and recurrent vulvovaginal candidosis (RVVC). A prospective study of women with vaginitis symptoms was conducted over 2 years in the regional clinic of population and family education in Sfax. A discriminant analysis was used to evaluate the association between the incidence of Candida vaginitis and potential risk factors. Sporadic and recurrent VVC were documented respectively in 48% and 6.1%. The most frequent factors associated with positive Candida culture were employed women, uncontrolled diabetes, history of genital infection and intrauterine device contraception. Increased episode numbers of VVC and condom/spermicidal contraception were positively associated with recurrences. Candida albicans was the predominantly isolated species (76.3%) followed by Candida glabrata (19.3%). Infection with C. glabrata occurred in 34% and 17.5% of patients with RVVC and VVC respectively. The discriminant investigation had provided further insights into the basis for prevention and control of RVVC. Increased prevalence of C. glabrata in patients with RVVC and observed risk factors should be taken into consideration to achieve success in the management of this infection.


15.25A: Vulvovaginal Candidiasis - Biology

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Role of Molecular Biology in Diagnosis and Characterization of Vulvo-Vaginitis in Clinical Practice

The diagnosis of vulvo-vaginal complaints has always been enigmatic in obstetrics and gynecology. Patients with clear, pathognomonic symptoms end up with a proper diagnosis and treatment most of the time, but unfortunately we are now living in a world where women reach out to the Internet and readily get all information as to which disease their symptoms correspond to and also find the appropriate treatment "over-the-counter." Because of this trend, we as specialists are increasingly confronted with patients with complex and combined conditions. At the same time, extremely sensitive and accurate diagnostic tools are now being developed at a rapid pace, allowing the physicians to diagnose vulvo-vaginal disease with a substantially increased precision. Moreover, many of these molecular biology (MB)-based tests have become so common and affordable that self-sampling and self-testing are no longer utopia. On the other hand, too much information that is too readily available and that is too affordable also encompasses pitfalls, leading to gross overtreatment and psychological burden. As experienced caregivers, we should supervise these evolutions, define their place and proper use as diagnostic tools, utilize their potential as ad hoc tools to follow-up treatment efficacy and guide how such tools can be used for responsible self-testing. In the present paper, responding to the need for appropriate, quality assured and accessible tests for vulvo-vaginitis and the huge potential delivered by the rapidly developing MB methods, we recommend the need for a broad and regular discussion forum, composed of both clinical and technical experts and opinion makers, in order to match the needs with the huge opportunities and ideally combine the initiatives and forces into the same direction. This forum should then translate conceived strategies into regularly updated, evidence-based national and international guidelines.

Keywords: Trichomonas vaginalis Aerobic vaginitis Bacterial vaginosis Diagnosis Mycoplasma Screening Sexually transmitted infections Testing Vulvovaginal candidiasis Vulvovaginal candidosis.


Protective Effects of cis-2-Dodecenoic Acid in an Experimental Mouse Model of Vaginal Candidiasis

Objective: To evaluate the efficacy of cis-2-dodecenoic acid (BDSF) in the treatment and prevention of vaginal candidiasis in vivo.

Methods: The activities of different concentrations of BDSF against the virulence factors of Candida albicans (C. albicans) were determined in vitro. An experimental mouse model of Candida vaginitis was treated with 250 μmol/L BDSF. Treatment efficiency was evaluated in accordance with vaginal fungal burden and inflammation symptoms.

Results: In vitro experiments indicated that BDSF attenuated the adhesion and damage of C. albicans to epithelial cells by decreasing phospholipase secretion and blocking filament formation. Treatment with 30 μmol/L BDSF reduced the adhesion and damage of C. albicans to epithelial cells by 36.9% and 42.3%, respectively. Treatment with 200 μmol/L BDSF completely inhibited phospholipase activity. In vivo mouse experiments demonstrated that BDSF could effectively eliminate vaginal infection and relieve inflammatory symptoms. Four days of treatment with 250 μmol/L BDSF reduced vaginal fungal loads by 6-fold and depressed inflammation. Moreover, BDSF treatment decreased the expression levels of the inflammatory chemokine-associated genes MCP-1 and IGFBP3 by 2.5- and 2-fold, respectively.

Conclusion: BDSF is a novel alternative drug that can efficiently control vaginal candidiasis by inhibiting the virulence factors of C. albicans.

Keywords: C. albicans Candidiasis Virulence factor cis-2-dodecenoic acid.

Copyright © 2018 The Editorial Board of Biomedical and Environmental Sciences. Published by China CDC. All rights reserved.


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An epidemiological survey of vulvovaginal candidiasis in Italy. / Corsello, Salvatore Spinillo, Arsenio Osnengo, Giuseppe Penna, Carlo Guaschino, Secondo Beltrame, Anna Blasi, Nicola Festa, Antonio Cammarata, E. Tempera, G. Bergante, C. Biancheri, D. Bordonaro, P. Fallani, M. G. Fambrini, M. Busetti, M. Campello, C. De Santo, D. De Seta, F. Panerari, F. Strazzanti, C. Foresti, I. Matteelli, A. Borraccino, V. Caggiano, G. Lepera, A. Montagna, M. T. Noya, E. Schönauer, S. Dente, B. Ferrari, A. Dang, P.

Research output : Contribution to journal › Article › peer-review

T1 - An epidemiological survey of vulvovaginal candidiasis in Italy

N2 - Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9±2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.

AB - Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9±2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.