Diagnosis The symptoms of VVC consist of vulvar pruritus associated with a vaginal discharge that typically resembles cottage cheese.
1.
The discharge can vary from watery to homogeneously thick. Vaginal soreness, dyspareunia, vulvar burning, and irritation may be present. External dysuria (“splash” dysuria) may occur when micturition leads to exposure of the inﬂamed vulvar and vestibular epithelium to urine. Examination reveals erythema and edema of the labia and vulvar skin. Discrete pustulopapular peripheral lesions may be present. The vagina may be erythematous with an adherent, whitish discharge. The cervix appears normal.
2.
The pH of the vagina in patients with VVC is usually normal (<4.5).
3.
Fungal elements, either budding yeast forms or mycelia, appear in as many as 80% of cases. The results of saline preparation of the vaginal secretions usually are normal, although there may be a slight increase in the number of inﬂammatory cells in severe cases.
4.
The whiff test is negative.
5.
A presumptive diagnosis can be made in the absence of fungal elements confirmed by microscopy if the pH and the results of the saline preparation evaluations are normal and the patient has increased erythema based on examination of the vagina or vulva. A fungal culture is recommended to confirm the diagnosis. Conversely, women with a normal physical examination findings and no evidence of fungal elements disclosed by microscopy are unlikely to have VVC and should not be empirically treated unless a vaginal yeast culture is positive.
Treatment The treatment of VVC is summarized as follows: 1.
Topically applied azole drugs are the most commonly available treatment for VVC and are more effective than nystatin (16) (Table 18.2). Treatment with azoles results in relief of symptoms and negative cultures in 80% to 90% of patients who have completed therapy. Symptoms usually resolve in 2 to 3 days. Short-course regimens up to 3 days are recommended. Although the shorter period of therapy implies a shortened duration of treatment, the short-course formulations have higher concentrations of the antifungal agent, causing an inhibitory concentration in the vagina that persists for several days.
2.
The oral antifungal agent, ﬂuconazole, used in a single 150-mg dose, is recommended for the treatment of VVC. It appears to have equal efficacy when compared with topical azoles in the treatment of mild to moderate VVC (26). Patients should be advised that their symptoms will persist for 2 to 3 days so they will not expect additional treatment.
3.
Women with complicated VVC (Table 18.1) benefit from an additional 150-mg dose of ﬂuconazole given 72 hours after the first dose. Patients with complications can be treated with a more prolonged topical regimen lasting 10 to 14 days. Adjunctive