3-50
Using Basic Tools: Thick, white, curdy discharge adherent to side walls of the vagina (may look like cottage
cheese or be thick and white/yellow); later signs include erythema and edema of the vulva/vagina (perineal
rash with red, shiny appearance); fissures of the vulva; self-inflicted scratches of the vulva; swelling and
redness of the labia; abdominal exam will be benign.
Using Advanced Tools: Lab: KOH (potassium hydroxide) wet-mount examination yields yeast hyphae in
50-80% of patients (See Lab Procedures: Wet Mount and KOH Prep). Vaginal pH: will be < 4.7 in patient
with candida (test with urine dipstick).
Assessment:
Differential Diagnosis: Bacterial vaginosis, trichomonas, gonorrhea or chlamydial infection, atrophic
vaginitis (see Vaginal Discharge Table and STD chapter).
Plan:
Treatment
Patients with vaginal or vulvar itching only may be treated without physical examination. A thorough
disease-specific history must be taken to evaluate for complicating factors such as pelvic pain, lesions, fever
and risk factors for sexually transmitted disease. If any of these are present, evaluate accordingly; if not,
prescribe intravaginal therapy.
Primary: Various intravaginal azole agents used for 3-7 days (miconazole, clotrimazole are most common)
Alternative: Oral fluconazole 150 mg X 1
NOTE: Intravaginal antifungals may be used throughout pregnancy. Avoid oral fluconazole. Both intravaginal
and oral therapy are safe during breastfeeding.
Patient Education
General: Complete all medication as prescribed since incomplete treatment is a reason for recurrence.
Activity: Normal
Diet: Regular - some theorize that a low-sugar diet may be preventive in certain individuals.
Medications: Burning and erythema (sensitivity to meds) may accompany treatment; discontinue and treat
with oral fluconazole.
Prevention and Hygiene: Wipe urethra/vagina from front to back. Wear cotton underpants and loose
clothing. Wash underwear in hot water.
No Improvement/Deterioration: Return immediately for reevaluation
Follow-up Actions
Return evaluation: Treat with standard intravaginal medication for 2 weeks. Reevaluate for possible
coexisting infection or misdiagnosis (bacterial vaginosis, trichomonas, GC/Chlamydia). Consider testing for
diabetes and HIV.
Consultation Criteria: Symptoms which do not respond to therapy; 4 or more recurrences per year;
complicating symptoms (pelvic inflammatory disease - patients with candida only do not have pelvic pain).
Symptom: GYN Problems: Pelvic Inflammatory Disease
MAJ Ann Friedmann, MC, USAIntroduction: Pelvic Inflammatory Disease (PID) results from organisms spreading directly from the cervix
to the endometrium (uterine lining) and then to the Fallopian tubes. Fallopian tube damage from untreated
PID is a major cause of infertility. Risk factors for PID: Sexual exposure to gonorrhea or chlamydia, uterine
instrumentation (IUD insertion, D & C, abortion, endometrial biopsy), bacterial vaginosis, prior history of PID
or STD. Diagnosis should be based on clinical exam and diagnostic tests. Many women perceived to be at
increased risk will not have PID, and many who do not have the typical risk profile will have PID. Many women
with PID may exhibit subtle, vague or mild symptoms. A high index of suspicion is necessary. PID is most
common in sexually active, menstruating, non-pregnant women.