Causes and treatment of vulvovaginal candidiasis. Vulvovaginal candidiasis Vulvovaginal candidiasis treatment

Thrush in women or vulvovaginal candidiasis is one of the most common reasons for seeking help from an antenatal clinic. This frequent occurrence is due to the widespread occurrence of the pathogen in the environment.

The causative agent of vulvovaginal candidiasis is a fungus of the genus Candida. This opportunistic microorganism has an oval or round shape. Unlike other fungi, they do not form true mycelium; their pseudomycelium is formed due to the elongation of their own cells, which, adjacent to each other, form chains.

The most favorable conditions for their reproduction are an acidic environment and a temperature of 21 to 37 degrees. Several representatives of the genus are of clinical importance - C. albicans, C. glabrata, C. tropicalis, C. krusei, C. parapsilosis.

Up to 70% of all cases are associated with C. albicans, however, recently the proportion of other pathogens has been increasing. Candida resistance to available antifungal drugs is also increasing.

The issue of sexual transmission of candidiasis is still controversial. How is it transmitted? Should I treat my sexual partner? The questions are relevant, everyone has their own answers.

The fact is that in the medical literature there is information that in men whose partners are being treated for VVC, the pathogen is detected only in 50% of cases.

The remaining 50% are either completely healthy or have another type of fungus.

Therefore, you should know that if a woman has a laboratory-confirmed episode of thrush, her sexual partner also needs to undergo smears and, if a pathogen is detected, undergo treatment.

Treatment is definitely required for men with clinical manifestations - inflammation of the glans penis, itching, swelling, cheesy deposits.

The sexual partner, of course, can be blamed for being the source of infection. However, this would not be correct. Almost 80% of people first encounter candida in the maternity hospital, receiving it from their mother, when passing through the birth canal, or simply from the environment. The fungus settles on the skin and mucous membranes and can exist there peacefully all its life without causing any problems to the owner.

The causes of thrush in women are the most commonplace - decreased immunity.

Why is thrush dangerous?

Vulvovaginal candidiasis in women most often manifests itself only in damage to the genitourinary system. There is no danger to life. Problems can be expected in several cases:

• lack of adequate treatment, while large areas are involved in the process, including the skin, which means it becomes a woman’s companion for life;
• a very strong decrease in immunity and the spread of the infectious process through the lymphatic and blood vessels to other organs and tissues, generalization of the process, sepsis (occurs extremely rarely in very weakened patients);
• vulvovaginal candidiasis during pregnancy is dangerous due to the possibility of the process spreading from the vagina to the uterus, to the fetus (fortunately, this is also rare);
• Thrush during lactation can spread to the nipples, and there is also a high risk of injury to the baby.

For convenience, we will try to divide the causes of thrush in women into several groups.

External or exogenous causes include:

1. Effect of drugs on immunity. When taking hormonal drugs, as well as cytostatics, the immune system is suppressed and the body's ability to adequately respond to an infectious threat is reduced.
2. A woman taking combined oral contraceptives. Previously, it was believed that thrush was provoked by those OCs that contain high doses of estrogens. However, in practice, everything depends on the patient’s body - any of the hormonal contraceptives available on the market can lead to the development of candidiasis.
3. Acute infectious diseases, especially those that require antibiotics. Antibiotics suppress the growth and reproduction of not only pathogenic microbes, but also normal flora, without affecting fungi and viruses in any way, and in the absence of competition, candida begins to multiply intensively.
4. Injuries and microtraumas of the vaginal mucosa under the influence of chemical, inflammatory, mechanical factors. If we specify this point, it can be endless - the mucous membrane is injured during sexual intercourse, when washing with soap and other surfactants, when using spermicides, when STIs enter the body, etc.

Another group of factors contributing to the development of thrush are internal:

• diseases of endocrine organs: thyroid disease with hormonal dysfunction, menstrual irregularities.
• nutritional factors– insufficient intake of vitamins and microelements from food (anemia, hypo- and avitaminosis).
• diseases and functional disorders gastrointestinal tract.
• pregnancy.

The signs of thrush are quite widely known. The classic course implies the presence of itching, burning, swelling, cheesy discharge, and pain.

Itching, burning and swelling appear under the influence of mediators (biologically active compounds) of inflammation, which, acting on receptors, lead to an increase in blood supply to the affected tissues and their irritation. Itching and burning intensify in the evening, after a long stay on your feet.

The culprits of pain are the same inflammatory mediators. The pain intensifies after urination, after sexual intercourse. Sometimes it becomes so intense that a woman refuses sexual activity altogether, which can disrupt her relationship with her partner.

The discharge is most often abundant, yellow in color, cheesy, and has a creamy consistency. Sometimes the discharge is liquid, interspersed with “cottage cheese”, and has an unpleasant odor.

If the lesion spreads to the skin, complaints such as redness, swelling, pinpoint rash, maceration of the skin, itching in the perineum and anus appear.

The chronic form of candidiasis is characterized by a process duration of more than 2 months, the main familiar symptoms fade into the background, tissue atrophy and infiltration predominate.

Up to 10% of women may suffer from recurrent vulvovaginal candidiasis. At the same time, clinically pronounced and laboratory-confirmed episodes of thrush are recorded 4 or more times a year.

The most accessible method for diagnosing candidiasis is a microscopic examination of a smear. The sampling is carried out by a specialist using a cytobrush or a Volkmann spoon, after which the material is applied to a glass slide, dried, fixed and stained in the laboratory and examined under a microscope.

In an acute process, clusters of yeast cells are found in smears; in a chronic process, clusters of pseudomycelium are found.

Currently, the method of express diagnosis of candidiasis is widespread - ready-made test systems are sold in pharmacies and allow you to confirm or refute the diagnosis in a short time, even at home.

Another fairly accessible, but at the same time troublesome, method is cultural or “seeding”.

Considering the difficulties in storing and delivering the material, the long waiting time for results, and the need for a special laboratory, it is resorted to in case of difficulty in making a diagnosis and to obtain the sensitivity of the pathogen to antifungal drugs when standard treatment regimens are ineffective.

PCR diagnostics can also be used to detect a fungus, however, the method is relatively expensive, and very often the question of overdiagnosis arises - the pathogen can be detected in completely healthy women who do not require treatment (the method allows you to complete a DNA chain from a small fragment of a cell).

The treatment of thrush should be carried out by a specialist, it should be comprehensive, in compliance with the rules for taking medications.

Self-medication without confirming the diagnosis can result in chronicity of the inflammatory process. Under the mask of thrush, other diseases may be hiding, the treatment of which with antifungal drugs will not have any effect.

Once the diagnosis of vulvovaginal candidiasis is laboratory confirmed, a treatment regimen is selected. In case of an acute episode, preference should be given to local forms - suppositories, vaginal tablets, creams. Although oral medications have proven their effectiveness, they have a systemic effect, i.e. act on other organs and tissues.

Local medications are divided into azole derivatives and antifungal antibiotics. The first group includes clotrimazole, miconazole, econazole, butoconazole, isoconazole, and ketoconazole. The second includes nystatin and natamycin. Regardless of which drug was prescribed, there is one requirement - a full course of treatment.

The average course of local antifungal agents is 6-7 days, but there are both drugs that require longer use - nystatin, and drugs whose course is limited to a single administration - isoconazole, butoconazole.

The price of antifungal drugs largely depends on the reputation of the manufacturer. In the article we indicated international common names so as not to single out anyone and not to offend anyone.

Of the antifungal drugs for oral administration, azole derivatives - fluconazole and itraconazole - can be prescribed for the treatment of vulvovaginal candidiasis; they are convenient with a short treatment regimen, affordable (the cost again depends on the manufacturer), but are contraindicated in pregnant and lactating women. Itraconazole is also contraindicated in children.

In addition to antifungal drugs, after the main treatment, agents can be prescribed to restore the vaginal biocenosis and stimulate the immune system. Proper nutrition and intimate hygiene are important.

Widespread and, oddly enough, quite effective. Let’s immediately say, of course, that traditional methods of treatment are good in combination with standard antifungal therapy. They help alleviate the condition and speed up recovery. As monotherapy, traditional methods of treatment are not always effective.

Most often, the vulva and vagina are treated with a soda solution. To do this, you need to dilute a tablespoon of soda in a liter of warm water, stir well and wash yourself 2 times a day, immediately before inserting a suppository into the vagina.

Soda is also used for douching; douching is performed with an enema with a soft spout until the discharge is completely washed out. To increase the effectiveness of the procedure, you can add a teaspoon of iodine to the soda.

Among folk methods, infusions of plant materials - chamomile, calendula, oak bark, birch buds, etc. - have also proven effective. To prepare the infusion, you need to pour 2 tablespoons of dry raw materials with 1 liter of boiling water. Leave for thirty minutes in a thermos, cool and use as directed twice a day.

For women, preference should be given to douching or washing; for little girls, preference should be given to sitz baths. Baths are effective for lesions of the labia and vulva.

The duration of the procedure is no more than 5 minutes, twice a day for 7-10 days. Each time the solution is prepared fresh, before immersion, you should wash the anal area with warm water and soap.

Douching is contraindicated for pregnant women and in the first months after childbirth, because the infection can flow through the cervical canal into the uterine cavity and spread to its membranes, causing endometritis and infection of the fetus.

Vulvovaginal candidiasis during pregnancy. How to treat?

For the treatment of uncomplicated forms of thrush during pregnancy, preference is given to vaginal forms of antifungal drugs. They are practically not absorbed from the vagina, do not have systemic effects and do not have a harmful effect on the fetus.

From the first trimester, natamycin is allowed, from the second the list expands significantly - clotrimazole, miconazole, butoconazole. Among complex preparations, Terzhinan vaginal tablets are widely used.

Antifungal drugs for oral administration during pregnancy are prescribed only if the infection becomes generalized and can threaten the woman’s life.

Prevention of thrush in women

To prevent thrush, a woman must follow the rules of personal hygiene, avoid casual sex, monitor her health and eat right.

It is recommended to limit the use of detergents when caring for the genitals, avoid synthetic underwear and tight clothing, and minimize the use of panty liners and lubricants.

It is necessary to introduce fiber, fermented milk products into the diet, enrich it with a sufficient amount of vegetables and fruits, it is recommended to exclude fast food, fatty, spicy foods, limit sweets and starchy foods, and alcohol.

Most women have experienced vulvovaginal candidiasis at least once during their lives. In 40–45% of patients, the disease recurs, and 5% of women suffer from a chronic form of the pathology.

Many people underestimate the danger of a fungal infection and ignore its first symptoms. Without adequate treatment, the disease progresses and reduces the quality of life. Pathogenic microorganisms spread to healthy tissue and create new lesions. The longer vulvovaginal candidiasis develops, the more difficult it is to cure.

About the disease

Vulvovaginal candidiasis is an infectious disease that is accompanied by inflammation of the mucous membrane of the vulva, vagina, urethra and perineal skin. Its causative agents are yeast-like fungi of the genus Candida. Vulvovaginal candidiasis is most often caused by the species. From 80 to 92% of episodes of pathology fall on its share. In other cases, representatives are identified:

• C. glabrata;
• C. tropicalis;
• C. guillermondii;
• C. parapsilosis;
• C. Kefir.

The cells of fungal microorganisms have a round shape. Their sizes range from 1.5 to 10 microns. Yeast-like fungi create pseudomycelium, which is formed due to the elongation of their cells. The causative agents of the disease are anaerobes. These are organisms that require oxygen to support the process of energy synthesis. Candida fungi actively reproduce in conditions of high humidity and at temperatures of 20–37 °C. The most favorable pH level for them is 6.0–6.5.

Yeast-like fungi Candida are widespread in nature. They are found in vegetables, fruits, dairy products, and also on the surfaces of objects. They are resistant to adverse conditions. Fungal microorganisms die only after prolonged boiling (10–30 minutes). They remain viable for half an hour when exposed to dry steam at a temperature of 95–110 °C. Fungi can withstand very acidic environments (pH 2.5–3.0) for long periods of time, although their development is slowed down under such conditions.

Based on the nature of its course, vulvovaginal candidiasis is divided into acute and chronic. The first form of the disease lasts no more than 2 months. Chronic pathology can be recurrent and persistent. The first periodically worsens - at least 4 episodes per year. Between them, the woman feels completely healthy. In the persistent form, the symptoms of the disease are observed constantly, sometimes decreasing, sometimes increasing.

Fungal infection most often develops in women of reproductive age. The peak incidence occurs between the ages of 20–45 years.

Reasons for development

Candida fungi are considered opportunistic microflora. They are present in small quantities on the skin and mucous membranes of healthy people, without causing the development of diseases. Fungal microorganisms are necessary. They help dispose of dead and dangerous cells.

The number of colonies of fungal flora is controlled by the immune system and beneficial bacteria, which are part of the human microbiocenosis. Therefore, healthy people rarely encounter fungal diseases and do not know what it is.

Uncontrolled use of medications

Candida fungi acquire pathogenic properties when the immune system weakens or the number of beneficial microorganisms sharply decreases.

The widespread use of fungal infections contributes to:

• antibiotics;
• cytostatics;
• immunosuppressants;
• hormonal drugs (especially first generation);
• oral contraceptives.

Poor personal hygiene

The development of the disease is provoked by vaginal tampons and sanitary pads. Because of them, a favorable environment for the proliferation of fungal microorganisms is created in the perineal area.

Pregnancy

Pregnancy influences the development of fungal disease. During pregnancy, the likelihood of vulvovaginal candidiasis increases by 2–3 times. The main causes of the disease include an increase in the concentration of estrogens and progestins in tissues.

Recurrent forms of vulvovaginal candidiasis often develop against the background of impaired carbohydrate metabolism in patients with diabetes mellitus. They are characterized by frequent exacerbations and are difficult to treat.

Chronic vulvovaginal candidiasis is often a consequence of self-medication. Advertising of antifungal drugs and their availability cause uncontrolled use of medications.

Incorrectly selected medications do not suppress the reproduction of pathogens, while weakening the body's defenses.

Severe forms of vulvovaginal candidiasis occur as a result of low patient compliance. This term refers to the degree to which the patient complies with the doctor’s recommendations. If the patient voluntarily shortens the course of treatment and reduces the dosage of drugs, fungal microorganisms survive and become resistant to the drug. In this case, it becomes more difficult to achieve a therapeutic effect.

Characteristic symptoms

The acute form of vulvovaginal candidiasis is characterized by pronounced symptoms. A woman suffers from unbearable itching in the vulva and vagina. It intensifies in the evening, at night, and also after a long walk. The itching is so severe that the patient cannot resist scratching.

As a result, micro-wounds appear on the mucous membrane, through which pathogens penetrate deep into the tissues. Due to severe itching, which can also occur in the anal area, sleep is disturbed and neuroses develop.

In addition to itching in the genital area, burning and pain are noted, especially in the scratching area. Unpleasant sensations intensify during urination, preventing complete emptying of the bladder.

Excruciating itching, burning and pain accompany sexual intercourse. Over time, a woman develops a fear of sexual contact.

A characteristic sign of vulvovaginal candidiasis is the appearance of leukorrhea (leukorrhea). They may have a thick (creamy) or flaky consistency. The gray-white discharge looks a little like cottage cheese and has a mild sour odor. Sometimes they are watery with cheesy clots that look like crumbs. In some cases, the disease proceeds without the formation of leucorrhoea.

The skin in the affected area turns red, swells and softens. On it you can find small red nodules and gray-white deposits of a round or oval shape. The size of cheesy spots with a sour odor can reach 5–7 mm in diameter. They can merge into large formations with clear boundaries, surrounded by areas of severely reddened mucous membrane. They contain a huge amount of quickly multiplying Candida fungi.

If candidiasis is diagnosed in the acute stage, plaque is difficult to remove. Beneath them, a bleeding, eroded surface is exposed. In the chronic form of the disease, it is easy to get rid of cheesy films. After removing plaque from the tissues of the mucous membrane, a whitish cheesy liquid is released abundantly.

Symptoms usually begin a week before your period. During bleeding they appear less intensely.

In the chronic form of the disease, the mucous membrane of the genital organs becomes thick, dry and rough. Areas with signs of atrophy appear on it.

Treatment of the disease

At the initial stage of the disease, medications with antimycotic effects and antiseptics for external use are used. They allow you to create a high concentration of the active substance in the affected area, with minimal impact on the entire body.

If vulvar candidiasis is diagnosed, creams are used. When the vaginal mucosa is affected, suppositories, solutions and vaginal tablets are used.

During pregnancy, it is allowed to use antifungal agents in the 2nd and 3rd trimester, giving preference to topical drugs. Systemic medications are prescribed in extreme cases when the benefit to the mother outweighs the potential harm to the fetus.

Polyenes are used to treat fungal infections:

• Nystatin;
• Levorin;
• Amphotericin.

Imidazoles:

• Isoconazole;
• Ketoconazole;
• Bifonazole;
• Miconazole;
• Clotrimazole.

Triazoles:

• Fluconazole;
• Itraconazole

Fluconazole is considered the “gold standard” for the treatment of vulvovaginal candidiasis. Fungi of the species Candida Albicans are especially sensitive to it.

The affected areas are treated with antiseptic solutions (baking soda, boric acid, potassium permanganate). They are used for baths, douches or for wetting vaginal tampons. The doctor applies aniline dyes to the vaginal mucosa.

Antiseptic drugs in the form of suppositories are indicated (Betadine, Vocadine, Iodoxide). They are administered before bedtime. Boric acid can be prescribed in the form of vaginal capsules. In severe cases, hormonal creams (class 1 and 2 corticosteroids) are used.

Treatment of fungal infections is difficult due to the rapidly developing resistance of pathogens to drugs. Fungal cells mutate and produce enzymes that reduce the effect of the drug on them. They acquire “pumps” that literally release the active substance from the cells.

In order to overcome the problem of resistance of pathogenic microorganisms, a fundamentally new antimycotic drug Sertaconazole was created. Its molecule contains azole and benzothiaphene structures that reinforce each other. A single use of Sertaconazole for external use in the form of suppositories or cream is recommended.

Treatment of complicated forms of vulvovaginal candidiasis

Often, a fungal disease is complicated by a bacterial infection. In such cases, treatment of vulvovaginal candidiasis is carried out with complex preparations containing, in addition to antimycotics, antibacterial, hormonal or antiseptic substances.

The drug Macmiror contains the antimycotic Nystatin and the antibacterial agent Nifuratel. Macmiror is used externally and in the form of suppositories.

The combination of antimycotics with Metronidazole is justified. It is active against bacteria and protozoa. For the treatment of vulvovaginal candidiasis, the complex drug Neo-Penotran is used in the form of vaginal suppositories. They contain Miconazole and Metronidazole.

Combination agents have been successfully used: Travocort (Isaconazole nitrate + Difluorocortolone-21-valerate), (Miconazole + Metronidazole), Polygynax (Nystatin + Neomycin + Polymyxin) and Terzhinan (Nystatin + Neomycin sulfate + Ternidazole + Prednisolone).

Vulvovaginal candidiasis, or thrush, is a common female disease. It occurs against the background of excessive activity of Candida fungi in the vagina and vulva. It is their uncontrolled growth that leads to serious negative consequences. Statistics show that 97% of women have encountered this problem at least once in their lives.

It should be noted that a certain amount of Candida fungi is contained in the microflora of every healthy woman. Together with other organisms, they prevent the development of serious diseases.

Yeast fungi are opportunistic microflora, which, when any favorable changes occur in the body, provoke the development of vulvovaginal candidiasis. Most often, the reason for this is an imbalance in the vagina or an excessive weakening of the body’s immune abilities.

The properties of microorganisms do not change, only their number increases. Due to their accelerated growth, beneficial mushrooms, which are responsible for maintaining the necessary balance, are displaced from the microflora.

Causes

Vulvovaginal candidiasis occurs due to excessive activity of Candida fungi. These yeast-like organisms are present in a certain amount in the body of every person. However, when any favorable conditions appear, they begin to reproduce immediately. This immediately affects the woman’s well-being; she immediately begins to experience discomfort in the vaginal area. The most common cause of this disease is:

• Significant weakening of the body's immune abilities.
• Incorrect, unbalanced and poor nutrition.
• Constant stress and emotional turmoil.
• Hypothermia and radical climate changes.
• Using panty liners, which harbor bacteria.
• Wearing synthetic underwear that does not allow the skin to breathe.
• Pregnancy, breastfeeding, hormonal changes.
• Allergic reaction and menopause.
• Long-term use of a number of medications.
• Sexual contact with a carrier of bacteria.
• Ignoring personal hygiene rules.

Research shows that the presence of yeast-like fungi in the body affects how often a woman encounters infectious and viral diseases. The more of these organisms, the weaker the immune system. It is very important to regularly keep it in good shape.

Symptoms

Recognizing vulvovaginal candidiasis is quite simple. With the right approach to diagnosis, the doctor will be able to determine this disease in just one visit. Typically, the presence of such a disease is indicated by the following signs:

• dysuric symptoms (impaired urination);
• severe itching and burning on the mucous membrane;
• copious discharge that somewhat resembles cottage cheese;
• unpleasant odor from the genitals;
• the fact that itching increases significantly during bathing, after sex and in the evening;
• dyspareunia (pain during sexual intercourse).

With vulvovaginal candidiasis, a woman can immediately recognize a number of symptoms of discomfort. Many patients complain of serious discomfort in the external genitalia, especially itching. They also develop a greyish, cheesy discharge that is quite viscous and sticky. The lady constantly experiences discomfort when walking and urinating for a long time.

You can also notice manifestations of such thrush when examined on a gynecological chair. The doctor can diagnose slight bleeding, swelling of the vulva, and redness of the mucous membrane. The white plaque itself is difficult to separate even with the help of medical instruments, and hides serious erosion underneath. If treatment is not started in time, the following complications may occur:

• difficulties in conceiving and bearing a fetus;
• genitourinary system infections;
• risk of pelvic infection;
• vaginal stenosis;
• premature birth;
• rupture of membranes;
• natural abortion;
• Chorioamnionitis.

Diagnostics

In order for treatment to bring the maximum amount of positive effect, it is very important to undergo a comprehensive diagnosis. It should include the following studies:

1. Smear microscopy - helps determine the presence of fungus.
2. Cultural culture will determine the type of pathogen and its sensitivity to certain pathogenic microorganisms.
3. Serological method - determines the sensitivity of the fungus to a number of antibiotics.
4. Immunofluorescence diagnostics - determines the amount of Candida in the body.
5. Polymerase chain reaction - helps determine what other pathogenic organisms are present in a person's blood.

In most cases, for a full diagnosis of vulvovaginal thrush, it is enough to conduct smear microscopy and culture. Such studies are repeated a week after the end of drug therapy in order to determine the effectiveness of the chosen method of exposure.

Treatment

Treatment of vulvovaginal candidiasis involves the use of systemic and local drugs. It should be noted that at the moment there is no specific and only correct treatment regimen - in each case, therapy is selected individually.

It is very important to consult a qualified doctor who will evaluate all the features. When determining an antifungal drug, you need to choose one that will be effective in combating a specific pathogen. It should be noted that today there are a lot of antimycotic drugs with a wide spectrum of action.

Local medications are of particular importance in the treatment of thrush. They help quickly get rid of itching and burning, suppress the activity of fungi in tissues. Most often, doctors prescribe Fluconazole to their patients - 1 capsule once a day for a week. Also, do not forget to treat the mucous membranes with Clotrimazole. It should be noted that every 10 women are diagnosed with a complicated form of candidiasis. In this case, more powerful drugs are prescribed, and the duration of therapy is significantly increased.

Treatment in pregnant women

Statistics show that every third pregnant woman faces the problem of vulvovaginal candidiasis during pregnancy. The fact is that during this period of life, serious hormonal changes occur in the body, which lead to an exacerbation of chronic thrush. It is also favorable for the pathogen that the environment in the vagina becomes less acidic. Often pregnant women do not eat properly, which aggravates the course of the disease.

Candidiasis poses a serious danger to an unborn baby. Fungi quickly penetrate the placenta and infect the umbilical cord, mucous membranes and skin of the baby. Infection can also occur during childbirth. Typically, special treatment for this problem is not carried out if the child is more than 2 months old.

All antifungal drugs are highly toxic and can cause serious harm. Treatment of thrush in this case consists of using vaginal suppositories. To prevent the occurrence of vulvovaginal candidiasis, a woman should adhere to the following rules:

• Remember to use condoms during sexual intercourse with a new partner.
• Carefully observe the rules of personal hygiene.
• Stop taking hormonal contraceptives.
• When treating with antibiotics, use antifungal suppositories.
• Eat properly and nutritiously.
• Take vitamin complexes regularly.
• Avoid douching, which disrupts acidity.
• Monitor your daily routine.
• Give up bad habits such as smoking and drinking alcohol.

With the help of simple rules, you will be able to not only strengthen the body, but also prevent the occurrence of vulvovaginal candidiasis. If you lead a correct and healthy lifestyle, this disease will not affect you. If serious discomfort occurs, try to contact your doctor as soon as possible.

Remember, the sooner you start taking medications, the sooner you will be able to overcome this disease. Don't forget to get tested regularly, which can detect overactive Candida fungi before any symptoms appear.

Rogovskaya S.I. RMAPO, Moscow.

ETIOLOGY

Vulvovaginal candidiasis (VVC) remains one of the most commonly diagnosed inflammatory diseases of the vagina and vulva, affecting the majority of sexually active women. Most often, VVC manifests itself as an acute inflammation that is easy to diagnose and treat. However, periodic episodes may be characteristic, usually with an unobvious cause and varying symptoms, which complicates diagnosis and therapy. Nonspecific symptoms are characteristic of many vaginal infections and doctors have to identify reliable signs for diagnosis.

It is not always possible to associate vaginal complaints with yeast fungi, and conversely, their presence does not necessarily confirm the fact of vulvovaginitis of fungal etiology. Therefore, in the literature, candosis is often considered as a syndrome with chronic problems of vulvovaginal discomfort, while VVC itself appears to be only a small part of the serious problem of mycoses.

The causative agents of candidiasis are yeast-like fungi of the genus Candida, there are more than 180 species. These are opportunistic microorganisms widely distributed in the external environment. Yeast-like fungi Candida are single-celled microorganisms. As saprophytes, they live on the skin and mucous membranes of healthy people. Fungi of the genus Candida are blastospores, reproduce by budding, and are aerobes. C. Albicans has the greatest significance in the occurrence of the disease, being its causative agent in 85-90%. Etiology different from C. albicans (C. Crusei, C. Tropicalis, C. Pseudotropicalis, C. Stellatoidea, C. Parapsilosis, Torulopsis glabrata, etc.) is noted more often in women over 35 years of age or using barrier contraceptives. Less commonly, C. kefyr and C. guilliermondii are isolated in vaginal candidiasis, and very rarely other Candida species are isolated.

Fungi - the causative agents of candidiasis - are considered opportunistic. Their danger for women varies widely and largely depends on the state of the macroorganism as a whole, the presence of risk factors and concomitant pathology.

EPIDEMIOLOGY

Under the data of I.D. Sobel, 75% of women have at least one, and 40-45% have two or more episodes of genitourinary candidiasis during their lifetime. Candidiasis carriage is observed in 3-5% of examined pregnant and non-pregnant women. According to other data, approximately 15% of non-pregnant and 30% of pregnant women isolate Candida cultures from vaginal discharge samples. VVC is the most common form of vaginal infection in pregnant women (35%), and in their structure there is a decrease in the role of C. Albicans (52%) and an increase in the role of Candida non-albicans due to C. Glabrata (12%) and C. parapsilosis (7% ), C. tropicalis (5%), mixed infections (14%). Recurrent vulvovaginal candidiasis (at least four episodes of the disease per year) affects about 5% of women of childbearing age.

TRANSMISSION, PATHOGENESIS AND RISK FACTORS

The causative agents of urogenital candidiasis are spread predominantly sexually, and risk factors such as immunosuppression, pregnancy, concomitant inflammatory and other diseases, the use of intrauterine and hormonal contraceptives, taking corticosteroid drugs, antibiotics, etc. are important. The importance of sexual transmission for vaginal candidiasis is small , although its possibility (during coitus from a woman to a predisposed man and vice versa) is not denied. Promiscuity is not associated with an increased incidence of colonization or infection. Factors predisposing to the development of the disease are also wearing tight clothing, obesity, poor hygiene conditions, and hot climate.

The pathogenesis of VVC is complex and depends on numerous exogenous and endogenous factors. In the development of candidiasis, the following stages are distinguished: attachment (adhesion) of fungi to the surface of the mucous membrane with its colonization, penetration, entry into the connective tissue of the lamina propria, overcoming tissue and cellular protective mechanisms, penetration into blood vessels, hematogenous dissemination with damage to various organs and systems.

The infectious process is most often localized in the superficial layers of the vaginal epithelium. At this level, the infection can persist for a long time due to the emergence of a dynamic equilibrium between fungi, which cannot penetrate the coarser layers of the mucous membrane, and the macroorganism, which restrains them but is not able to completely eliminate the pathogen. Violation of this balance leads either to an exacerbation of the disease, or to remission or recovery. Vaginal specimens contain yeast-like fungi that reproduce asexually to form buds (blastoconidia). Fungi do not have true mycelium; they form pseudomycelium, which is formed due to the elongation of fungal cells and their arrangement in a chain. Penetration into cells, along with the integrity of the mannoprotein membrane, allows fungi to resist the defense factors of the macroorganism.

Many authors pay attention to changes in the composition of the vaginal microflora. In general, it should be recognized that changes in the aerobic and anaerobic microflora of the vagina during candidiasis are in most cases weakly expressed and do not allow us to assert the presence of dysbiosis that requires drug correction. Estrogen hormones increase the avidity of the vaginal epithelium to Candida spp., Progesterone also stimulates the adhesion of fungi to the genital epithelium. Moreover, yeast cells have receptors that recognize sex hormones. The immune disorder in vaginal candidiasis is predominantly local in nature. A decrease in antigen load after etiotropic treatment leads to the restoration of normal immunoreactivity. Immunomodulation by Candida antigens and the influence of sex hormones should also be taken into account.

A number of studies on genetic defects in humans indicate an increased susceptibility of some organisms to various types of candidal infections. The recurrent nature and chronic course of vaginal candidiasis are explained in different ways. One of the most common concepts until recently was the theory of reinfection. Exogenous infection from a sexual partner has not been proven. It has now been established that relapses of vaginal candidiasis are usually caused by one strain of the fungus. The cause of a chronic relapsing course is tended to be explained by the state of the patient’s body, primarily by the characteristics of the vaginal protective system.

CLINICAL MANIFESTATIONS

VVC is characterized by one or more of the following symptoms:

1. increase in the amount of discharge,

2. white with “milky” plaques, the color of the discharge,

3. itching, burning sensation or irritation in the external genital area,

4. inability to perform sexual intercourse due to severe pain when inserting the penis into the vagina,

5. unpleasant smell.

Currently, it is customary to distinguish 3 clinical forms of genital candidiasis:

1. Candidate carriers,

2. Acute urogenital candidiasis,

3. Chronic (recurrent) urogenital candidiasis.

Lesions in the external genital area caused by pathogens of superficial mycoses usually spread slowly and are accompanied by moderate subjective sensations. The edges of the mycosis focus are usually more hyperemic. Sometimes vesicles appear. The skin of the inner thighs, inguinal and intergluteal folds, and vulva is most often affected. Most often, Epidermophyton floccosum and Trychophyton rubrum are found in such foci, less often - Microsporum fulvum.

Chronic VVC is characterized by weak hyperemia and infiltration of the mucous membranes, scanty whitish films in the form of inclusions and islands, dry erosion without clear boundaries, lichenification and dryness of the labia minora and majora, excoriation, cracks. Changes in the external genitalia may resemble atrophic lichen: the skin and mucous membranes acquire a brown color, become flabby and atrophic, the labia majora and minora are smoothed or wrinkled, the opening in the vagina is narrowed, there are epidermal papules, linear excoriations and scars. Asymptomatic vaginal candidiasis is accompanied by hemorrhagic rashes on a normal or slightly bluish mucous membrane.

In the international literature, preference is given to dividing the nature of the course of VVC into an uncomplicated form and a complicated one.

DIAGNOSTICS

For laboratory diagnosis of VVC, it is preferable to use a microscopic method of examining a native or stained specimen. Indications for the cultural method of research are: chronic recurrent course of urogenital candidiasis, the need to determine the species of yeast-like fungi and assess their sensitivity to drugs, atypical course of the disease, etc. Candida grows well on simple nutrient media, including blood agar, wort agar, potato agar, Sabouraud medium with glucose or maltose. Clinical specimens for culture diagnosis of candidiasis should be processed as quickly as possible. Existing molecular biological methods for diagnosing VVC (PCR and real-time PCR) make it possible to identify C. albicans and other types of yeast-like fungi.

As with any infection with VVC, compliance with the rules for obtaining a clinical sample for microscopic examination is of utmost importance. It is advisable to examine a woman during the period of ovulation, 5 or more days after the last coitus, in the absence of taking antibacterial, antifungal, protistocidal drug systems during the 2 months preceding the examination, no douching the day before and on the day of the examination, urinary retention within 3-4 hours before receiving the biosample. The discharge from all possible areas of infection should be examined, namely the urethra, posterior lateral vaginal vault, cervical canal, rectal ampulla. Compliance with the requirements for obtaining a clinical sample from the urethra for microscopy allows us to increase the detection of laboratory signs of inflammation by almost three times and yeast fungi of the genus Candida by almost two times.

TREATMENT

Obviously, timely identification and, if possible, elimination of risk factors is a guarantee of the effectiveness of antifungal therapy, therefore the doctor is obliged to devote time during the patient’s appointment to adequately review the medical history. The management tactics for patients with VVC are largely determined by the course and etiological structure of the infectious-inflammatory process.

Limited, acutely developing superficial candidiasis of the skin and mucous membranes can be successfully treated with external means, and widespread, chronic forms of urogenital candidiasis require mandatory general (etiological and pathogenetic) therapy. To obtain consistent successful results, treatment requires persistent multilateral therapy with specific drugs using agents that reduce the influence of risk factors. Treatment regimens in accordance with the recommendations of the main most cited guidelines are approximately the same and are based on the results of evidence-based studies.

However, there are many drugs, and the number of commercial brands is even more limitless. Therefore, it is enough for a doctor to know the basic principles of managing women with VVC.

Candidiasis does not require therapy in the general sense if there are no clinical symptoms and various risk factors, which are assessed by the doctor in each case individually. The following are cases when treatment for candidiasis is necessary:

If candidiasis threatens to progress to the stage of acute candidiasis (in HIV-infected people, with multiple organ lesions, neutropenia).

If there are risk factors (a woman is taking antibiotics, glucocorticosteroids or cytostatics; in cases of sub- and decompensation of diabetes mellitus; if she is undergoing gynecological operations or invasive diagnostic interventions).

In case of risk of transmission of Candida from mother to fetus during pregnancy and childbirth.

Conda infection is dangerous for a sexual partner (suffering from decompensated diabetes mellitus or taking glucocorticosteroids, cytostatics, immunosuppressants, etc.).

In cases of acute (or uncomplicated) and even more so chronic (complicated) genital candidiasis, treatment is prescribed to all women without exception. In general, the principles of treatment of chronic candidiasis (complicated) are as follows:

1. Pathogenetic therapy (timely identification and, if possible, elimination of risk factors);

2. Etipotropic therapy (antimycotics);

3. Hyposensitizing drugs (yeast-like fungi are full-fledged antigens);

4. Antioxidants;

5. Vitamin therapy (especially B1, B2, C, PP);

6. Enzymes that improve digestion

7. Immunostimulation (strictly according to indications);

8. Hepatoprotectors at the end of the course of antimycotics;

9. Local treatment.

In recent years, the drug fluconazole (Mikosist), which belongs to a new class of triazole compounds, has found widespread use in the treatment of VVC. It inhibits the biosynthesis of fungal membrane sterols, binds a group of the cytochrome P-450-dependent enzyme lanosterol-14-demethylase of the fungal cell, disrupts the synthesis of ergosterol, as a result of which fungal growth is inhibited. The drug selectively acts on fungal cells, does not affect the metabolism of hormones, and does not change the content of steroids in women. According to international recommendations, tactics should be used to relieve exacerbations followed by maintenance therapy: two consecutive doses of fluconazole (the second 72 hours after the first), then suppressive treatment with 150 mg of fluconazole weekly for 6 months.

Possible reasons for relapses and ineffectiveness of VVC therapy can be regarded as the following:

1) unidentified and unresolved pathogenetic risk factors,

2) incomplete clinical diagnosis,

3) insufficient volume of antifungal therapy and/or incorrect choice of groups of antifungal drugs,

4) lack of examination and, if necessary, treatment of the sexual partner (reinfection),

5) suppression of nonspecific resistance of the body,

6) the presence of an intestinal reservoir of Candida spp.,

7) reduction of local immunity factors, etc.,

8) low compliance.

The issue of compliance is very important. Compliance is the degree of probability of how fully the patient will complete the prescribed course of treatment, taking into account all the doctor’s recommendations (adherence to the prescribed treatment). The patient’s resistance to treatment directly depends on the extent to which medical prescriptions interfere with the usual routine of life. In fact, only a third of patients fully follow the doctor's prescriptions. Many authors have shown that with a dosing regimen of 1 time per day, the doctor’s recommendations are followed by 74-90% of patients, 2 times a day - 57-70%, 3 times a day - 50-52%, 4 times a day - 40-42 %, i.e. Compliance deteriorates in parallel with an increase in the frequency of taking/using medications.

In view of this factor, the progress of pharmaceuticals is to reduce the frequency of use of drugs. It is clear that 100% compliance with treatment recommendations can only be achieved if the drug is used immediately and once after diagnosis, with a guarantee of cure and evidence-based clinical effectiveness in the absence of side effects. Such drugs already exist, in particular for the treatment of VVC.

Since Candida fungi initially infect the surface layers of the epithelium, the inflammatory reaction is weakly expressed or completely absent; topical antifungal drugs are quite effective and preferable. Butoconazole in the form of 2% vaginal cream (registered in the Russian Federation as “Gynofort”), which is included in the list of priority effective drugs for the treatment of VVC by the American Center for Disease Control and Prevention, SASHA, in the 2010 recommendations, is highly effective and safe.

Many women prefer topical forms of medications due to fear of side effects and systemic reactions. It is known that the less a drug is absorbed when administered locally, the more safe it is. Local administration of butoconazole allows for high concentrations of the active substance and minimal systemic absorption: only 1.7% of the administered vaginal dose enters the systemic circulation. However, the problem of local treatment of vaginal infections is the inconvenience of administration and leakage of most of the product when a woman gets out of bed, contamination of underwear, which many women consider unacceptable for themselves.

Vulvovaginal candidiasis (in common parlance - thrush) is an extremely common disease that is caused by infection of the vulva and vagina by yeast fungi of the genus Candida, and their excessive growth.

In 70 - 80% of cases, vulvovaginal candidiasis is caused by the fungus Candida albicans, one of the normal components of the microflora of a healthy vagina; in the rest, it is caused by its combination with other fungi of the same genus. Since yeast fungi are representatives of conditionally pathogenic microflora, symptoms of the disease appear when the vaginal environment is imbalanced, in conditions of decreased local or general immunity of the body. The properties of the fungi do not change, but a niche appears for their increased growth, and they displace beneficial microorganisms that preserve the vaginal microbiocenosis.

Experts distinguish three main forms of vulvovaginal candidiasis:

• Carriage of a fungal infection;
• Acute candidiasis vulvovaginitis (inflammation of the mucous membranes of the vulva and vagina);
• Chronic candidal vulvovaginitis.

Vulvovaginal candidiasis occurs in women of any age; its widespread distribution and the need for effective treatment represent a real medical and social problem.

Symptoms of vulvovaginal candidiasis

If they are carriers, women do not experience any noticeable symptoms; the presence of fungi is detected in vaginal smears, their number does not exceed normal limits.

Acute vulvovaginitis caused by candidal infection is expressed in copious vaginal discharge, which has a grayish-white color, cheesy consistency and sour smell, itching and burning sensations in the area of ​​the external genitalia and in the vagina itself, sometimes turning into painful. During a gynecological examination, swelling and redness of the vulva and vaginal walls are visible. There is no general deterioration in the patient's condition. Symptoms persist for 1.5 - 2 months.

Chronic fungal vulvovaginitis is characterized by a longer course and subsequent relapses.

The mucous membrane of the vagina and vulva undergoes inflammatory changes. Sometimes the infection affects the urethra and rises into the bladder, developing candidal urethritis and cystitis.

Causes of vulvovaginal candidiasis

The transmission of pathogens of vulvovaginal candidiasis through sexual contact raises some doubts. Fungi can also be found in men, but it has not been proven that a woman gets the infection as a result of sexual intercourse, because the disease also occurs in virgins. Yeast fungi can be introduced into the vagina from the intestines (especially if there are signs of dysbiosis) or from the oral cavity.

Fungal infection is activated during the use of hormonal drugs, including oral contraceptives, during treatment with antibiotics, and with the local use of spermicides. In the second phase of the menstrual cycle, as well as during pregnancy, postmenopause, in a word, with natural changes in female hormonal levels, an exacerbation of candidiasis is often observed.

The presence of inflammatory diseases of the female genital area also predisposes to its manifestations. In a normal state of immunity, vaginal lactobacilli suppress the growth of fungi, and candidiasis does not manifest itself in any way.

Diagnosis of vulvovaginal candidiasis

Vulvovaginal candidiasis in any of its forms is not difficult to diagnose - a gynecological examination and the results of a microscopic examination of a smear from the vagina and urethra are sufficient. The doctor may order additional tests to make sure there is no other specific infection and to accurately determine the species of the fungi.

Treatment of vulvovaginal candidiasis

Currently, there is a very wide selection of drugs for topical use that have two types of antifungal effects - fungicidal (destruction of fungi) and fungistatic (inhibition of their growth). These are intravaginal suppositories or tablets that are convenient for administration. They have virtually no side effects and eliminate the symptoms of the disease. General treatment - taking antimycotic drugs orally - is prescribed for chronic vulvovaginal candidiasis and penetration of infection into other organs.

Specialists at the DeVita clinic will help you select the most effective medications and provide comprehensive restorative treatment aimed at restoring the immune system and normalizing the vaginal microflora.