Vaginitis: Monilial

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Chapter 95 Vaginitis: Monilial

INTRODUCTION

Description: Monilial vaginitis is a vaginal infection caused by ubiquitous fungi found in the air or as common inhabitants of the vagina, rectum, and mouth.
Prevalence: Twenty-five percent to 40% of “vaginal infections;” 75% of women experience one or more lifetime occurrences.
Predominant Age: 15 to 50 (rare outside this range except for those receiving estrogen replacement after menopause).
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Candida albicans (80% to 95%), Candida glabrata, Candida tropicalis, or others (5% to 20%).
Risk Factors: Altered vaginal ecosystem (stress, antibiotic use, pregnancy, diabetes, depressed immunity, topical contraceptives, and warm and moist environment).

CLINICAL CHARACTERISTICS

Signs and Symptoms (15% asymptomatic carrier rate)

• Vulvar itching or burning (intense)
• External dysuria, dyspareunia
• Tissue erythema, edema, and excoriations
• Thick, adherent, plaquelike discharge with a white to yellow color (generally odorless)
• Vulvar excoriations

DIAGNOSTIC APPROACH

Differential Diagnosis

• Bacterial vaginitis
• Bacterial vaginosis
• Trichomonas vaginal infection
• Contact vulvitis (allergic vulvitis)
• Atrophic vulvitis
• Vulvar dermatoses
• Pinworms

Associated Conditions: Diabetes, immunosuppression or compromise (as risk factors for infection), chronic vulvitis.

Workup and Evaluation

Laboratory: Culture (Nickerson’s or Sabouraud media) or monoclonal antibody staining may be obtained but are seldom necessary.
Imaging: No imaging indicated.
Special Tests: Vaginal pH 4 to 4.5.
Diagnostic Procedures: Physical examination, microscopic examination of vaginal secretions in normal saline and 10% KOH (potassium hydroxide).

Pathologic Findings

Branching and budding of vaginal monilia distinguish monilial vaginitis from lint or other foreign material. The use of 10% potassium hydroxide lyses white blood cells and renders epithelial cells “ghostlike,” making identification easier.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Perineal hygiene (keep the perineal area clean and dry, avoid tight undergarments or those made of synthetic fabric), education regarding prevention, encourage completion of the prescribed course of therapy.
Specific Measures: Medical therapy.
Diet: No specific dietary changes indicated.
Activity: No restriction.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP028 (Vaginitis: Causes and Treatments).

Drug(s) of Choice

Imidazoles—miconazole (Monistat, 200-mg suppositories, every night at bedtime for 3 days, 2% cream, 5 g every night at bedtime for 7 days), clotrimazole (Femcare, Gyne-Lotrimin, Mycelex, 100-mg inserts, every night at bedtime for 7 days, 1% cream, 5 g every night at bedtime for 7 days), butoconazole (Femstat, 2% cream, 5 g every night at bedtime for 3 days), tioconazole (Vagistat, 6.5% ointment, 4.6 g every night at bedtime).
Triazoles—terconazole (Terazol, 80-mg suppositories, every night at bedtime for 3 days, 0.8% cream, 5 g every night at bedtime for 3 days, 0.4% cream, 5 g every night at bedtime for 7 days), fluconazole (Diflucan, 150 mg PO single dose).
Contraindications: Known or suspected hypersensitivity or allergy. Imidazoles are contraindicated during the first trimester of pregnancy. Fluconazole is a pregnancy category C drug.
Precautions: Topical steroid preparations should be avoided. Use of oral ketoconazole requires baseline and follow-up liver function studies. Gastrointestinal side effects are common with oral therapies.
Interactions: Oral fluconazole should be used with caution in patients taking oral hypoglycemics, coumarin-type anticoagulants, phenytoin, cyclosporine, rifampin, or theophylline.

Alternative Drugs

Povidone iodine (topical), gentian violet (1%), boric acid (600-mg capsules placed high in the vagina twice daily).

FOLLOW-UP

Patient Monitoring: Normal health maintenance, frequent recurrences should suggest host compromise (e.g., diabetes, human immunodeficiency virus, anemia).
Prevention/Avoidance: Good perineal hygiene, clothing and activities that allow perineal ventilation (cotton underwear, loose clothing).

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Possible Complications: Vulvar excoriation caused by scratching, chronic vulvitis, secondary vaginal or vulvar infections.
Expected Outcome: A small number (<5%) of fungal infections are resistant to imidazole therapy. Organisms causing these infections are generally susceptible to triazoles. Roughly 30% of patients experience a recurrence of symptoms within a month (related to a continuing exposure, a change in host defenses [such as altered cellular immunity], or the ability of the fungus to burrow beneath the epithelium of the vagina).

MISCELLANEOUS

Pregnancy Considerations: Vaginal infections are associated with an increased risk of premature delivery and premature rupture of the membranes.
ICD-9-CM Codes: 112.1.

REFERENCES

Level I

Phillips AJ. Treatment of non-albicans Candida vaginitis with amphotericin B vaginal suppositories. Am J Obstet Gynecol. 2005;192:2009.

Level II

Javanovic R, Congema E, Nguyen H. Antifungal agents vs. boric acid for treating chronic mycotic vulvovaginitis. J Reprod Med. 1991;36:593.

Level III

American College of Obstetricians and Gynecologists. Vaginitis. ACOG Practice Bulletin 72. Obstet Gynecol. 2006;107:1195.

Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291:1368.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:54.

Eckert LO. Clinical practice. Acute vulvovaginitis. N Engl J Med. 2006;355:1244.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:594.

Forssman L, Milsom I. Treatment of recurrent vaginal candidiasis. Am J Obstet Gynecol. 1985;152:959.

Horowitz BJ. Candidiasis: specification and therapy. Curr Prob Obstet Gynecol Fertil. 1990;8:233.

Marrazzo J. Vulvovaginal candidiasis. BMJ. 2002;325:586.

Mitchell H. Vaginal discharge—Causes, diagnosis, and treatment. BMJ. 2004;328:1306.

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