In 23 years of medical practice, the most common disease I encountered is vaginitis, and among vaginitis, candida vulvovaginosis (VVC) is definitely the most common, and recurrent (RVVC) is definitely a painful and difficult situation for many women, including myself. I had a very good patient, Nana, who had bilateral chocolate cysts for more than a year after surgery, and an Indian patient did it together. Nana is finally getting married and is planning to get pregnant at my urging (pregnancy is the best treatment for endometriosis). I promised her that I would do a comprehensive science and talk about the ins and outs of RVVC from a professional point of view, so I hope that all of you can benefit from it.
The first look at the true face of the mountain, VVC white belt and we eat a thing very similar, tofu sludge. Ha ha, many of our gynecological diseases are related to some of the eating it. The first one is like tofu crumbs, the second one is like cheese.
The following began to lecture, the children sit down: I. Overview
I. Overview
Recurrent vulvovaginal candidiasis refers to women with simple Candida vulvovaginitis, after treatment, clinical symptoms and signs 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 recurrent Candida vulvovaginitis.
Common symptoms
(i) Symptoms
Clinical manifestations: worsening in the week before the onset of menstruation, with some relief afterwards.
Pruritus: flushed, swollen skin, intense self-induced itching, which may be accompanied by a burning sensation in the 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.
(B) 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 wiped away, 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 have been involved, dry scaly areas with clear margins of infection (eczema-like changes) are seen. Sometimes scratches on the vulva or chapping of the vulvar skin may be seen.
(C) Diagnosis
Typical cases are not difficult to diagnose. It is easy to diagnose based on relevant medical history, predisposing factors, symptoms, signs and laboratory diagnosis. The diagnosis can be made by finding budding spores or mycelium in the patient’s secretions.
II. Causes of pathogenesis
(i) Pathogenesis.
1, diabetes, pregnancy, oral contraceptives, long-term treatment with antibiotics, adrenocorticosteroids and immunosuppressants 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.
(B) 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 low bacterial population, 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 impregnation 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 smooth has higher tolerance to alkaline environmental pH than Candida albicans, and is insensitive to imidazole drugs, 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. At present, it is found that Candida smooth is resistant to ketoconazole and 5-fluorocytosine, while Candida klebsiella is resistant to fluconazole.
Third, the examination method
1.Direct examination method
Is the most commonly used clinical test method, positive detection rate of 60%. Its advantage is simple, fast. Use a long sterilized cotton swab 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 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 stain 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 number of colonies with inoculation needle and smear them with 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, without the need for further culture to reduce the unnecessary costs involved. However, because microscopic examination is not a very sensitive method, so it is often necessary to make fungal culture to confirm the diagnosis.
4.Strain identification test
To determine the species of distinguishing Pseudostelium, it is necessary to conduct fermentation test, assimilation test, and identify the morphological characteristics of its colonies.
5.pH value determination
If the pH value is <4 or 5, it may be a simple Pseudomonas infection. If the pH value is >4 or 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.
Identification
Candida vulvovaginitis often coexists before, during or after the skin disease and has similarities. It is important to think about Candida vulvovaginitis, the presence of other skin diseases at the same time, and whether it is recurrent vulvovaginal candidiasis when there is vulvar itching, burning pain, local congestion, and skin lesions, or when treatment is ineffective.
Many pathogens can cause almost similar symptoms or signs, so it is important to differentiate.
Trichomonas vaginalis is an increased frothy vaginal discharge, which can sometimes be plagioid or purulent, with a foul odor. There may also be urethritis, cystitis, cervicitis, infection of the paraurethral glands and the Bartholin’s gland, and occasionally renal meningitis. 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.
V. Treatment
1.Western medical treatment
After the diagnosis of recurrent VVC, we should try to remove the causative agent.
Supportive treatment: active treatment should be given if there is diabetes mellitus. Stop using broad-spectrum antibiotics, estrogen and corticosteroids in time. Change underwear regularly and wash used underwear, basins 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 treatment, 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 with a monthly dose of fluconazole 150 mg;
Itraconazole 400 mg orally in two divided doses during menstruation;
Vaginal clotrimazole 500mg 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 such as Saccharomyces cerevisiae, Candida tropicalis and Candida smoothus infections, gelatin borate 600mg can be given intravaginally once/day until the fungal test is negative, usually for 10-14 days.
Regardless of the regimen used for treatment, a significant number of patients relapse within a short time after stopping treatment. One follow-up visit at 7-14 d, 1 month, 3 months and 6 months (usually after menstruation) after the end of treatment.
2.Chinese herbal treatment.
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 bitterns 10g Radix et Rhizoma white fresh bark 20g Radix et Rhizoma ganoderma 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.
Recipe: Poria 20g Poria 10g Zeligia 10g Plantago 10g Insecticide and Anti-itch, Flea Hugh 30g Wild Chrysanthemum 10g White Flower and Snake Tongue Herb 30g. In the formula, Poria, Poria, Zeligia, Plantago and Insecticide clear heat and remove dampness, Flea Hugh, Wild Chrysanthemum and White Flower and Snake Tongue Herb 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 medication
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.
Complications
Pseudomonas infection is easily combined with other pathogens and 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 loss of 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 will easily cause inflammation upward, causing cervicitis and cervical erosion, and if the pathogen enters the uterine cavity, it will cause inflammation of the fallopian tubes and ovaries, pelvic inflammatory disease, etc., and finally affect pregnancy.
VII. Prevention
(1) Pseudomonas infection should be thoroughly treated for the first time, checked for systemic diseases, detected and treated in time
(2) Don’t douche the vagina often, as this can easily break the 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 penile corpus.
In conclusion, the occurrence of Candida vulvovaginitis is multifactorial and prevention should be individualized. Measures should be taken for each corresponding link so as to reduce recurrence or prevent infection.
Eight, self-care
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 Candida at 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 infection, so more attention should be paid to rest.
Nine, diet
Patients often ask: doctor, what do I need to pay attention to diet? So I found some things to share with you.
(A) food therapy (for reference only)
1.Mixed fresh lotus root
20 grams of mung beans, 300 grams of fresh lotus root, 3 fresh mint leaves. Wash and peel the fresh lotus root, soften the mung beans with water, fill the lotus root 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 residue, cook the porridge with round-grained rice, and then mix in rock sugar when serving. Take 2-3 times a day for 7-10 days as a course of treatment. This formula has the function of clearing damp heat in the liver and gallbladder.
6.Lentil flowers, Tsubaki white skin
Take 9 grams of lentil flowers and 12 grams of Tsubaki bark, wrap the medicine in gauze, add 200 ml of water, decoct 150 ml and take. This formula can clear heat and dampness.
(B) Suitable food
1, choose a light diet, food rich in vitamin A, B2, C, such as animal liver, fish eggs, carrots, etc.; eggs and fresh vegetables, such as tomatoes, spinach, amaranth, beans, beans, lotus root, etc.; eat more fresh fruit, such as citrus, orange, grapefruit, lemon, strawberries, sour dates, 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 wheat, pumpkin and other foods. Can reduce itching symptoms, but should not be excessive
(C) unsuitable food
(1) hair products. Such as sea fish, shrimp, crab, river fish, lake fish, etc., after eating will aggravate the vulva 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.