A common undesired visitor after summer vacations
by Dr. Aikaterini Raka*
Vulvovaginitis by the yeast of Candida species (spp.), also known as vaginal candidiasis, is an inflammation of the vaginal mucosa and the skin of the urogenital area that affects millions of women worldwide regardless their social status and the development of therapeutic techniques, especially during the summer.
Candida spp. are widely found in nature. Many species are harmless commensals or endosymbionts of hosts including humans, pets, and wild animals. In humans, Candida spp. can be found as part of the normal flora of the intestine and the vagina. In other words, these yeasts may colonize the mucosa of these areas in small numbers and coexist with the normal microbial flora without causing any harm to the host as long as the gut flora and the vaginal Lactobacilli remain in high numbers.
Statistics point out that 70-75% of women will be infected at least once in their lifetime, and usually those of reproductive age. Additionally, 40-50% of these women will relapse during the year at least once, while 4-8% of them will relapse about 4-5 times during the year.
Statistics have also shown that 20% of healthy asymptomatic women are colonized with Candida spp. Furthermore, 30% of vulvovaginitis cases are due to this yeast, while the rest are due to bacterial infections.
According to studies, in the 1980s and 1990s, U.S. spent for diagnosis and treatment around 1 billion US dollars annually, a number that has been doubled today due to the emergence of resistant strains created by the widespread improper use of antibiotics and anti-fungal drugs and the increase of the autoimmune diseases.
Biology
Most cases (85-95%) of vaginal candidiasis are due to the species Candida albicans, whereas the rest are due to the species of Candida glabrata and less to other species such as Candida parapsilosis, Candida tropicalis, and Candida cruzei. It is possible, although there is no clinical evidence and records at present, that in the near future a new strain will emerge, that of Candida auris. This species is also responsible for relapsing vaginal candidiasis and resistance to treatment, showing ever-increasing incidences.
Candida spp. thrives at moist environments of acidic pH (i.e., less than 4). Therefore, a vaginal pH around 6 and a urogenital area as dry as possible is of primary importance to prevent the development of the infection. In other words, sweating reduces the pH of the vagina due to the acids that sweat includes. Additionally, sweat is happening when the temperature is high since the body uses this mechanism as a reaction to the elevated temperature and thus rendering the infection more possible to happen.
Symptoms
- Pain
- Burning sensation
- Swelling of the genitals
- Localized elevated temperature and ruddiness
- Loss of functionality of the area with dyspareunia (pain during intercourse)
- Difficulty urinating
- White or yellowish discharge
- Itching and abrasions of the skin of the vulva
The symptomatology is often similar to bacterial infections, with minor differences, which is why self-diagnosis and the use of therapeutic ointments or drugs by the patient herself should be avoided. A visit to the gynaecologist, urologist or dermatologist is the appropriate course of action when these symptoms appear, which often concern not only the woman, but also her partner, with the same symptoms.
Studies show the recent development of antifungal drug-resistant and relapse-prone fungal species, and incompletely treated fungal infections after use of single-dose suppositories and ointments or reckless use of antifungal agents – the same issues that doctors deal with bacteria and abuse or incomplete treatment with antibiotics.
Every woman with vaginal candidiasis must visit her gynaecologist who will obtain a vaginal swab which will be brought to the microbiological laboratory immediately for microscopic examination of the fresh sample and its stained version (Gram stain). The sample will then be inoculated into special nutrient agars where potential bacteria and/or fungi will grow. Depending on the microbial growth, an antibiotic sensitivity test will follow for the determination of the appropriate treatment.
Risk factors (predisposition)
The development of vaginal candidiasis is more likely in women with a suppressed immune system (e.g., AIDS, hepatitis, etc., people with genetically predetermined immunodeficiencies, cancer patients undergoing radiation therapy or chemotherapy, transplant recipients, the elderly, etc.). DNA deciphering showed that some women with ABO LEWIS blood group had an increased chance of Candida colonization, vulvitis and relapsing with this fungus, due to the fungus’s affinity for the vaginal mucosa. Furthermore, the use of antibiotics predisposes to the appearance of vaginal candidiasis due to the destruction of the normal flora of the vagina, along with the elimination of the pathogenic bacteria for which they are administered. Other predisposing factors are Type II Diabetes, pregnancy, and the use of birth control pills.
Prevention
Prevention of the disease includes the use of cotton underwear that absorbs moisture and, in general, well-ventilated clothes to avoid sweating, washing the genital area with special products that protect the vaginal flora, avoiding contact with wet sand during the summer, and taking precautions during sexual intercourse. When there is a urogenital infection, fungi should always be the first consideration during diagnosis. Cooperation among the personal doctors, Biopathologists and the microbiological laboratory is vital for the final diagnosis and treatment of the infection.
*Biopathologist – Microbiologist, Member of the Medical Team of Yiannoukas Medical Laboratories – BIOIATRIKI Healthcare Group in Cyprus.
References:
Achkar JM, Fries BC.. Candida infections of the genitourinary tract. Clin Microbiol Rev. 2010 Apr;23(2):253-73.
Sobel JD. Vulvovaginal candidosis. Lancet 2007; 369: 1961–71
Goncalves et al. Vulvovaginal candidiasis: Epidemiology, microbiology and risk factors. Crit. Rev. Microbiol. 2015 ; 905-927.
