Recurrent vulvovaginal candidiasis is a condition in which a woman has simple Candida vulvovaginitis and after treatment, clinical signs and symptoms disappear and fungal tests are negative, then symptoms appear and are positive again by fungal tests, which can be called recurrent Candida vulvovaginitis. If there are 4 or more episodes in 1 year, it is called recurrent vulvovaginal candidiasis. It is a common and persistent gynecological disease with a complex etiology and a wide range of factors leading to recurrence. It is estimated that 5% of adult women suffer from recurrent and intractable vulvovaginitis.
Causes of recurrent vulvovaginal candidiasis
I. Pathogenesis
Pathogenesis.
1, Diabetes, pregnancy, oral contraceptives, long-term treatment with antibiotics, adrenocorticosteroids and immunosuppressive agents are the most common causative factors.
2. Oral metronidazole for bacterial vaginosis or bacterial excess syndrome can also induce Candida vulvovaginitis.
3. It is closely related to intestinal host and sexual transmission. Women with recurrence have about 20% of their male partners with Candida parasites in their penis.
4, Zinc deficiency can induce recurrent VVC. Zinc not only affects the immune function of the body, but also may be involved in the growth and proliferation of Candida albicans.
5, certain sexual behaviors can cause recurrent attacks of VVC, such as frequent kissing, menstrual sex, have anal sex experience, etc. The age of the first sexual intercourse is significantly correlated with the occurrence of RVVC, and the younger the age the higher the prevalence.
Psychological factors: Affected women often lack self-esteem and are more likely to be depressed, while vulvovaginal candidiasis also plagues their emotional and sexual lives.
Genetic predisposition: Non-secretory women with Lewis phenotype Le(a-b-) have a significantly higher prevalence than control healthy women.
II. Pathogenesis
Candida is present in the vaginal mucosa, female external genitalia and their surrounding skin. It is mainly in a non-mycelial state with a relatively small number of bacteria, in which a delicate balance is maintained between the presence of Candida albicans and the presence of protective mycelium in the host, as well as its local defense mechanisms. At this time, the organism has sufficient immune capacity to stop the invasion of Candida albicans. When the balance is disturbed, Candida albicans grows and multiplies locally, converting from the yeast phase to the mycelial phase, causing skin, mucous membrane and even systemic pseudomonal yeast disease.
In women with recurrent vulvovaginitis, there is a change in cytokines, secreted as IL-4, IL-5 and IL-10. IL-4 has the potential to attract eosinophils, so eosinophils are easily found in the vaginal secretions of women with recurrent vulvovaginal candidiasis, as well as IgE produced by mast cells. the above suggests that the Candida host with recurrent vulvovaginitis, in terms of immunity There is a tachyphylactic reaction in which the patient is allergic to his own yeast, i.e. the host shifts from a normal prophylactic response mediated by Th1 cells to a Th2 response. It has also been reported that with Candida albicans dip as a skin test solution, most have an immediate positive skin reaction and a few have an immediate negative skin reaction, but a delayed skin positive reaction occurs after 6-8 h, also indicating host immune abnormalities (Rigg D, 1990).
The pathogenesis of vulvovaginitis with recurrent Candida is related to immune mechanisms, but also microbial factors. It is known that the main fungus of Candida vulvovaginitis is Candida albicans, which accounts for about 80%, and non-Candida albicans, such as Candida smoothis infection without hyphae but only germinating yeast, and this budding spores are difficult to identify under the microscope and can easily confuse the diagnosis. Candida glabrata has higher tolerance to alkaline environmental pH than Candida albicans, and is not sensitive to imidazoles, making it difficult to treat thoroughly and prone to recurrent attacks. Candida can change its antigenicity under the action of antifungal drugs to escape the action of drugs. Currently, Candida smoothis is found to be resistant to ketoconazole and 5-fluorocytosine, while Candida klebsiella is resistant to fluconazole.
Symptoms of recurrent vulvovaginal candidiasis
Recurrent vulvovaginal candidiasis reappears after the elimination of symptoms, signs and fungi after treatment, and ≥ 4 episodes in a year.
1. Clinical manifestations: aggravated one week before the onset of menstruation, with some relief after the menstruation.
Pruritus: flushed and swollen skin, intense self-conscious itching, may be accompanied by burning sensation in vulva and vagina. Symptoms worsen when the environment is warm or when wearing tight-fitting clothes or synthetic fabrics.
Increased leucorrhea: white flaky film or curd-like material covering the inner labia minora and vaginal mucosa. A large amount of white, thick, curd-like or tofu-like leukorrhea.
There may be vaginal pain, irritation and difficulty in sexual intercourse.
2. Physical signs
The vaginal mucosa may have varying degrees of edema and erythema, which may extend to the ectocervix. The vaginal discharge often adheres to the vaginal wall in the form of lumps, and when the lumps are removed, the red and swollen mucosal surface is revealed. In the acute stage, damaged erosions and superficial ulcers can be seen underneath the white masses.
Sometimes there are also small nodules and blisters at the edges of the inflammation, and if large areas of surrounding tissue are involved, dry scaly areas with clear margins of infection (eczema-like changes) are seen. Sometimes scratches on the vulva or chapped vulvar skin can be seen.
3.Diagnosis
Typical cases are not difficult to diagnose. It is easy to diagnose based on relevant medical history, triggering factors, symptoms, signs and laboratory diagnosis. The diagnosis can be made by finding budding spores or mycelia in the patient’s secretions.
Diagnosis of recurrent vulvovaginal candidiasis
Tests and examinations for recurrent vulvovaginal candidiasis
1, direct examination method. It is the most commonly used clinical test, with a positive detection rate of 60%. The advantage is that it is simple and quick. A longer sterilized cotton swab is used to take vaginal and cervical secretions or milky white film on the vaginal wall as the specimen to be examined.
(1) Saline method: Take a little of vulvovaginal discharge, apply it on the carrier slide and add 1 to 2 drops of saline to mix.
(2) Potassium hydroxide method: take a small amount of secretion on a slide, add 1 drop of 10% potassium hydroxide solution or isotonic sodium chloride solution, cover with a coverslip and then microscopically examine, and find the budding spores and pseudomycorrhizae under the microscope after mixing. If more pseudomycelia are found, it means that Candida is in the pathogenic stage, which is more meaningful for diagnosis. Since 10% KOH can dissolve other cellular components, the detection rate of pseudofilamentous yeast is higher than saline, and the positive rate of checking asymptomatic hosts is 10%, while the positive detection rate of symptomatic vaginitis is 70% to 80%.
2. Gram staining method. This method has a positive detection rate of 80%. After smear and fixation of the secretion, Gram stain is applied and observed under the microscope, clusters of Gram positive ovoid spores and pseudomycorrhizae can be seen. After staining with Congo red stain or PAS stain, the positive rate was higher than that of direct microscopy. Gram staining, spores and pseudomycorrhizae stained blue: Congo red and PAS staining, spores and pseudomycorrhizae are stained red.
3.Culture method. If pseudomycotic vaginitis is suspected and the test is negative for several times, fungal culture can be done. Take the specimen and inoculate it on Sha’s medium, put it in 37℃ and observe it after 24~28h. A large number of small and white colonies can be seen, pick a small amount of colony smear with inoculation needle, direct microscopic examination or microscopic examination after staining, a large number of budding spores can be seen, which can be initially diagnosed as Candida infection. The culture positive rate can be almost 100%. Pseudomonas culture is mainly to observe the colony morphology, color, odor and microscopic performance. The entire culture plate is first examined under 10 times magnification, which is sufficient to distinguish yeast cells, pseudomycorrhizal bodies and primary wall spores. Further, the different species can be distinguished by biochemical tests for sugar, nitrogenous compounds and vitamin consumption.
Usually, the diagnosis can be made if the patient has a typical clinical presentation and budding spores and pseudomycorrhizae are seen under the microscope, and no further culture is needed to reduce the unnecessary costs involved. However, because microscopic examination is not a very sensitive method, it is often necessary to make fungal culture to confirm the diagnosis.
4.Strain identification test To determine the type of distinguishing pseudofilamentous yeast, it is necessary to conduct fermentation test, assimilation test, and to identify the morphological characteristics of its colonies.
5.pH value determination. If the pH value is <4.5, it may be a simple Pseudomonas infection. If the pH value is >4.5 and there are a lot of white blood cells in the smear, it suggests a mixed infection of trichomonas or bacterial vaginosis.
6. For old and obese patients or those who have been untreated for a long time, urine sugar and blood sugar should be checked to find the cause.
7. Antibodies to Candida albicans can be detected by immunodouble amplification or latex gelation.
Differential diagnosis of recurrent vulvovaginal candidiasis
Candida vulvovaginitis often coexists with similarities before, during or after the skin disease. It is important to think about Candida vulvovaginitis, the presence of other skin diseases at the same time, and recurrent vulvovaginal candidiasis when there is vulvar itching, burning, local congestion, and skin lesions, or when treatment is ineffective.
Itching, burning sensation and increased leucorrhea in the vulva are not always due to Pseudomonas infection. Many pathogens can cause almost similar symptoms or signs, so they must be differentiated.
Trichomonas vaginalis. The vaginal discharge is frothy and sometimes plagioid or purulent, with a foul odor. There may also be urethritis, cystitis, cervicitis, infection of the paraurethral and Bartholin glands, and occasionally nephrogenital nephritis. Difficulty in urination, hematuria and nocturia may be present. Vaginal examination reveals characteristic signs of cervical congestion, vaginal wall congestion, edema, and bleeding spots with a strawberry-like appearance. Trichomonas vaginalis may be detected.
Complications of recurrent vulvovaginal candidiasis
With Pseudomonas infection there is a tendency to combine mixed infections of other pathogens and complications of other STDs such as AIDS, condyloma acuminata, gonorrhea and non-gonococcal vaginitis.
The change in pH of the vagina can inhibit sperm motility, and inflammatory cells can engulf sperm and reduce sperm motility. Candida albicans has the effect of agglutinating sperm, as well as painful intercourse and decreased libido when inflammation occurs, all of which can affect pregnancy. This kind of infertility can return to normal soon after active treatment. If Candida vaginitis is left untreated for a long time, it can easily cause inflammation upstream, leading to cervicitis and cervical erosion, and if the pathogen enters the uterine cavity, it can cause inflammation of the fallopian tubes and ovaries, pelvic inflammatory disease, etc., which finally affects pregnancy.
Prevention and treatment of recurrent vulvovaginal candidiasis
(1) Those with first occurrence of Pseudomonas infection should be treated thoroughly, checked for systemic diseases, detected and treated in time
(2) Do not douche the vagina frequently, as this tends to break the internal vaginal environment and cause dysbiosis.
(3) Improve the local environment of the vagina: from the perspective of infection prevention, advise women not to wear tight, non-breathable chemical fiber underwear and use pads for a long time, but to wear looser, breathable and moisture-absorbing underwear, keep the area dry and pay attention to vulva cleanliness. To put shorts and towels in the sunlight of ventilation
(4) Do not take antibiotics casually, improve the body’s immunity, eat less sweets and drink more yogurt. Biological agents with therapeutic properties such as dairy products containing Lactobacillus acidophilus can prevent pseudomonal vaginitis and intestinal infections without significant side effects, thus reducing dependence on antifungal drugs. Therefore, this biological preparation can be tried in patients susceptible to Pseudomonas infection, and its effect may be to restore the normal flora ratio.
(5) Advocate simultaneous treatment of the affected woman and her sexual partner: Pseudomonas vulvovaginitis is a sexually transmitted disease, and sexual partners of patients with Pseudomonas vulvovaginitis have a certain percentage of positive rates of Pseudomonas in their oral cavity, semen and coronal groove of the penis.
In conclusion, the occurrence of Candida vulvovaginitis is multifactorial and prevention should be individualized. Measures should be taken for each respective link, thus reducing recurrence or preventing infection.
Chinese medicine treatment of recurrent vulvovaginal candidiasis
Chinese medicine treatment: The bed is often based on the amount, color, odor and general condition of the leucorrhea.
Clearing heat and dampness, killing worms and relieving itching.
The formula: Acorus calamus 10g Phellodendron 10g Poria 20g Atractylodes macrocephala 10g Psyllium 10g Radix et Rhizoma 10g Radix et Rhizoma 10g Radix et Rhizoma 10g Radix et Rhizoma 20g Radix et Rhizoma Guanzhong 10g. If the patient has symptoms of spleen deficiency, such as poor diet and unformed stools, add 30g of yam, 10g of Atractylodes Macrocephala and 10g of Atractylodes Macrocephala.
Formula: Poria 20g Poria 10g Zeligia 10g Plantago 10g Insecticide 10g Insecticide 10g Bai Xian Pi 20g Hesperus 10g Flea Huo 30g Wild Chrysanthemum 10g White Flower and Snake Tongue Herb 30g. formula with Poria, Poria, Zeligia, Plantago and Insecticide to clear heat and remove dampness, Bai Xian Pi, Hesperus to kill insects and relieve itching, Flea Huo, Wild Chrysanthemum and White Flower and Snake Tongue Herb to clear heat and detoxify. If the patient has symptoms such as frequent urination, urgent urination and painful urination, 10g of Mucuna pruriens and 20g of Slippery Rock can be added.
Topical application
20g of each of Serpentine and Bitter Ginseng, decoction for external washing, twice a day for 10 days as a course of treatment.
Add 100g of Mucuna pruriens, decoct to 100mL with water, and use cotton swabs dipped in the liquid to scrub the vagina once a day for 7-10 days.
Add a little glycerin to ice borax and stir well. After washing the vagina, apply the powder to the vagina with a cotton swab, once in the morning and once in the evening.
Add glycerin and apply the powder to the vulva and vagina with a cotton swab, once in the morning and once in the evening.
Western medical treatment of recurrent vulvovaginal candidiasis
I. Treatment
After the diagnosis of recurrent VVC, we should try to remove the causative agent.
Supportive treatment: active treatment should be given if diabetes mellitus is present. Timely discontinuation of broad-spectrum antibiotics, estrogens and corticosteroids. Change underwear regularly, and wash used underwear, basin and towels with boiling water.
Initial treatment: Oral or topical preparations are available and often require daily medication until the patient’s symptoms disappear and Candida cultures are negative. Without consolidation therapy, 30% of patients with recurrent VVC relapse within 3 months.
Oral dosing.
Itraconazole 200 mg twice daily for 2 to 3 d. Or 50 to 100 mg/d for 6 months.
Fluconazole 150 mg, repeated once after 3 d for a total of 3 d. Subsequent maintenance doses of 200 mg were used once weekly for 6 months.
Ketoconazole 100 mg/d for 6 months.
Vaginal dosing.
Miconazole suppository 400 mg once a night for 6 d.
Miconazole suppository 200 mg once a night for 7 to 14 d.
Clotrimazole suppositories 500 mg, repeated once after 3 days.
Clotrimazole suppository 100 mg once a night for 7 to 14 d.
Consolidation regimen.
Monthly menstrual period in one dose of fluconazole 150 mg;
Itraconazole 400 mg orally in two divided doses during menstruation;
Clotrimazole 500mg vaginally before menstruation;
Vaginal placement of miconazole 400mg/day for 3 days before menstruation.
In rare cases where conventional imidazole therapy is ineffective, possibly related to rare strains of yeast, Candida tropicalis and Candida smoothus, gelatin borate 600mg can be given intravaginally once/day until the fungal test is negative, usually for 10-14 days.
II. Prognosis
Regardless of the regimen used for treatment, a significant number of patients relapse within a short time after stopping treatment. At the end of treatment 7-14
d, 1 month, 3 months and 6 months (usually after menstruation) after the end of treatment.
Care of recurrent vulvovaginal candidiasis
1. Wear cotton underwear and change them regularly. Separate towels and basins for washing the vulva. Do not wear pantyhose or tight jeans continuously. The direction of wiping after a bowel movement should be from front to back so that the Candida from the anus will not be brought to the vagina.
2, try to maintain a cheerful mood, because psychological reasons can also reduce the body’s immunity, so that Candida take advantage of the situation.
3. The immune function of the body changes during menstruation, making it susceptible to Candida infections, so more attention should be paid to rest.
What is good to eat for recurrent vulvovaginal candidiasis?
Vulvovaginal candidiasis food therapy (for reference only, specific need to ask the doctor)
1.Mixed fresh lotus root
20 grams of mung beans, 300 grams of fresh lotus root and 3 pieces of fresh mint leaves. Wash and peel the lotus root, soften the green beans with water, fill the lotus hole, steam and slice, chop the fresh mint, sprinkle on it, season and serve cold.
2.Mung bean stew with large intestine
Pork large intestine, mung beans, septoria each appropriate amount of mung beans boiled for 20 minutes, put into the large intestine (both ends tied tightly) and septoria cooked together, add seasonings for consumption.
3.Dietary seeds red dates soup
30 grams of groundnut, 5 red dates, water decoction, 2 times a day.
4.Kelp and mung bean soup
Add kelp (chopped), mung beans and sugar, add water and boil soup together, take once a day for 10 days.
5.Incan 30 grams of round-grained rice 50 grams of rock sugar
First, boil the juice of Inoceramus with an appropriate amount of water, remove the slag, cook the porridge with round-grained rice, and then mix in rock sugar when serving. Take 2 to 3 times daily for 7 to 10 days as a course of treatment. This formula has the function of clearing damp heat in the liver and gallbladder.
6. 9 grams of lentil flowers and 12 grams of white peel of Tsubaki, wrap the medicine in gauze, add 200 ml of water, decoct 150 ml and take. This formula can clear heat and dampness.
What is good for vulvovaginal candidiasis patients to eat?
1, choose a light diet, it is advisable to eat foods rich in vitamin A, B2, C, such as animal liver, fish eggs, carrots, etc.; poultry eggs and fresh vegetables, such as tomatoes, spinach, amaranth, string beans, beans, lotus root, etc.; eat more fresh fruits, such as citrus, orange, grapefruit, lemon, strawberry, sour date, hawthorn, etc.
2, vulvar itching should eat more nutritious food, such as chicken, milk, tofu, beans, etc.
3, appropriate supplementation of vitamin A, vitamin B2 and folic acid, such as cod liver oil, carrots, animal liver, fish, apricots, whole grains, pumpkin and other foods. It can reduce itching symptoms, but not in excess
What are the best foods for vulvovaginal candidiasis patients not to eat?
(1) Hairy foods. Such as sea fish, shrimp, crab, river fish, lake fish, etc., after eating will aggravate vulvar itching, so should be avoided.
(2) Tobacco and alcohol. Because they can aggravate the inflammation and congestion, making the itchy pubic, so should be avoided.
(3) spicy, irritating food. Such as chili, pepper, fennel, pepper, onion, etc., can make the inflammation expand, the pubic itching more, so should be avoided.
(4) fried, sweet and greasy food. Such as lard, cream, butter, fried pork chops, fried steak, milk sugar, chocolate, etc., can help wet effect, is not conducive to treatment, so should be avoided.