Recurrent vulvovaginal candidiasis
Introduction
Introduction to recurrent vulvovaginal candidiasis Recurrent vulvovaginal candidiasis refers to women suffering from simple candida vulvovaginitis. After treatment, clinical symptoms and signs disappear. After the mycological examination is negative, symptoms appear again and are positive by mycological examination. Candida vulvovaginitis recurrence, such as 4 or more episodes within 1 year, it is called recurrent vulvovaginal candidiasis. basic knowledge Sickness ratio: 25% Susceptible people: more common in women Mode of infection: non-infectious Complications: Condyloma acuminata Gonorrhea
Cause
Causes of recurrent vulvovaginal candidiasis
(1) Causes of the disease
The reasons for recurrence are as follows:
1. Incomplete treatment, fungi in the vagina, antibiotic application, sexual partners, environmental factors, etc.
2. Oral metronidazole treatment of bacterial vaginosis or excessive bacterial syndrome can also induce Candida vulvovaginitis.
3. Closely related to intestinal host and sexual transmission, women with recurrence, about 20% of their male partners have Candida parasitization.
4. Uncontrolled diabetes, wearing chemical fiber tights and other related factors are also the susceptibility and predisposing factors of recurrent vulvovaginal candidiasis.
(two) pathogenesis
Pathogenesis of recurrent vulvovaginal candidiasis
1. Recurrent vulvovaginal candidiasis has an immunopathogenic process (Figure 1).
The above diagrams have fully demonstrated that the pathogenesis of recurrent vulvovaginal candidiasis is also related to the immune mechanism. The reason for the decreased reactivity of T lymphocytes to Candida antigen is due to the production of prostaglandin E2 by the patient's macrophages, prostaglandin E2 may Lymphocyte proliferation is blocked by inhibiting the production of interleukin-2, which may be caused by local IgE anti-candida antibodies or a serum factor.
All women may have yeast colonization. Many patients can migrate for several months or even years, but under the immune protection of the body, only a small amount of yeast is maintained in the symbiotic relationship, and immunoglobulin IgE and IgA are maintained. This symbiotic relationship has less effect, and cell-mediated immunity plays a major role, that is, Th1 secretes IL-1, IL-2 and TNF and other pro-inflammatory factors, while Th2 secretes IL-4 and the like to inhibit cellular immunity, between Th1 and Th2. Mutual inhibition, mutual antagonism to maintain balance.
In women with recurrent vulvovaginitis, cytokines have changed, and IL-4, IL-5 and IL-10 are secreted. IL-4 has the potential to attract eosinophils, so recurrent vulvovaginal candidiasis Eosinophils are easily found in women's vaginal secretions, and IgE produced by mast cells can also be found. The above shows that the recurrent vulvovaginal candida host has an immediate allergic reaction in immunity, and the patient has his own yeast. Allergies, that is, the host's transition from a normal preventive response mediated by Th1 cells to a Th2 response, have also been reported to be immersed in Candida albicans as a skin test solution, most of which have a positive skin test positive reaction, and a few immediate skin reactions are negative, but at 6 A skin-positive delayed response occurred after ~8 h, indicating host immune abnormalities (Rigg D, 1990).
2. The incidence of vulvovaginitis of recurrent Candida is related to the immune mechanism, as well as microbial factors. The main fungus of Candida vulvovaginitis is known to be Candida albicans, accounting for about 80%, and non-Candida albicans. For example, when Candida glabrata is infected without hyphae and only germinated yeast, the blastospores are difficult to identify under the microscope, which is easy to be confused. The tolerance of Candida glabrata to alkaline environmental pH is higher than that of Candida albicans. Imidazole drugs are not sensitive and are difficult to treat thoroughly and are prone to recurrent attacks.
Prevention
Recurrent vulvovaginal candidiasis prevention
1. Prevention of vulvovaginal candidiasis
(1) For the first occurrence of Candida infection, it should be thoroughly treated: Candida albicans can grow on the surface of the mucous membrane or invade the deep layer. If the infection is insufficient, if the time is too short, it is not easy to completely kill the sterile silk and spores. It is prone to drug resistance, resulting in recurrent vulvovaginal candidiasis. Therefore, it is very important for the first patient to be thoroughly treated. Local treatment or combined systemic therapy can be used, and consolidation treatment can be used, that is, repeated treatment 10 days after the initial treatment.
The standard of thorough treatment for the first time was that the symptoms disappeared after the initial treatment, the signs returned to normal, the Candida microscopic examination was negative, and three consecutive menstrual examinations were performed, all of which were negative.
It has also been proposed that preventive use of antifungal drugs for recurrent vulvovaginal candidiasis, once a month for 6 months, or topical use of antifungal drugs, once a week for 6 months, can also be effective Prevent recurrence.
(2) Check for systemic diseases, timely detection and treatment: The most suitable pH environment for Candida albicans growth in the vagina is 4 to 5. When various factors increase the amount of glycogen in the vagina, the acidity is most suitable for Candida. Breeding causes inflammation, blood sugar levels increase during diabetes, and local glycogen content in the vagina increases, thereby changing the normal pH value in the vagina, forming an internal environment conducive to the growth of Candida and causing infection. On the other hand, diabetic patients have more white blood cell functions. Defects, easy to combine bacterial infection, and the application of antibiotics is also easy to induce Candida vaginitis, therefore, for patients with recurrent candidal vaginitis should check blood sugar, for diabetic patients should strengthen blood glucose monitoring, so that blood sugar control at 6.11 ~ 7.77mmol / L, if the patient can not achieve the ideal blood sugar after diet treatment, the application of drugs to treat diabetes, through the systemic treatment to restore the local environment of the vagina to normal, is not conducive to the growth and reproduction of Candida.
(3) Improve the local environment of vaginal: The most suitable temperature for the growth of pathogenic Candida albicans is 37 ° C. The increase of local environmental temperature is more conducive to the growth of Candida. In addition to the low immune system function of the menstrual period, the local pH of the vagina changes, damp. Increased temperature is more likely to be secondary to Candida infection.
(4) Improve the body's immunity: Candida vulvovaginitis is both a localized disease and a systemic disease, that is, Candida is a conditional pathogen, that is, in host resistance and immunity When the host is pathogenic, gamma interferon can inhibit the production of PGE2 by macrophages, thereby inhibiting the formation of spores, germination, and growth of fungi. Therefore, for some diseases, the body's immunity is low, such as long-term use of immunosuppressants, etc., can be used interferon to prevent candida inflammation, the immune function of the body during menstruation will also change, prone to candida infection, so should pay more attention to rest.
(5) Strict control of antibiotic application: Candida albicans is one of the normal flora of the human body. About 10% of women have parasitic bacteria in the vagina without obvious symptoms. The application of antibiotics will affect the flora imbalance in the vagina and intestine. In particular, the current abuse of antibiotics is quite common, which makes the imbalance of microbial relationships, and it is easy to cause Candida to breed and cause disease. The longer the antibiotics are used, the more chances of infection with Candida, the more people using antibiotics. Uninfected Candida vulvovaginitis infection rate is 2 times higher, when using broad-spectrum antibiotics for 10 to 14 days, the chance of suffering from Candida vulvovaginitis is increased by 3 times, and the type of antibiotics has no significant relationship with Candida infection. (Spini-llo A, 1999), patients with continuous antibiotics for 10 days suffered from Candida vulvovaginitis accounting for 20%, while those who received antibiotics for one-time use did not find Candida infection.
The use of antibiotics is a short-term risk factor for Candida vulvovaginitis. Long-term use is the direct cause of the increased prevalence of Candida vulvovaginitis. Therefore, when there is infection in each system, the indications for antibiotic application should be strictly controlled, especially The application of broad-spectrum antibiotics pays more attention to timely withdrawal of drugs and oral antifungal drugs when necessary to prevent secondary candidal vulvovaginitis.
(6) Advocating the simultaneous treatment of sick women and their partners: Candida vulvovaginitis is a sexually transmitted disease. The sexual partners of Candida vulvovaginitis have a certain proportion of rosary in their mouth, semen and penis coronal sulcus. The positive rate of bacteria, clinically treated with sexual partners, the recurrence rate was significantly lower than that of the non-treatment group, and the recurrence rate was also low in the treatment group (recurrence rate was 15.8% in the treatment group and 44.8% in the untreated group). Especially for those who have oral sex, it is necessary to carry out Candida culture and strain identification of the patient's sexual partner semen and oral secretions. The treatment of the woman alone, the man is also susceptible to cross-infection, and the use of condoms can reduce cross-infection between sexual partners.
(7) Application of biological agents and dairy products containing acidophilic lactic acid bacteria: Biological agents with therapeutic properties such as acidophilic lactic acid bacteria can prevent diarrhea, antibiotic diarrhea, and prevent candidal vulvovaginitis and intestinal infections. There is no obvious side reaction, thus reducing the dependence on antifungal drugs. Therefore, the biologic preparation can be tried for patients who are susceptible to Candida, and the effect may be to restore the normal proportion of the flora.
The incidence of intestinal and vaginal candida infections was 3 times lower than that of uneaten patients, and the number of intestinal and intravaginal Candida colonies was significantly lower than that of the untreated children. In the edible group, daily intake of a certain amount of lactic acid products can reduce the formation of Candida colonies and reduce infection (Hilton E, 1992).
In short, the occurrence of Candida vulvovaginitis is a multi-factor, prevention should also be individualized, take appropriate measures for their respective links, thereby reducing recurrence or preventing infection.
2. Gynecological and family planning Candida infection problems through the vagina into the uterine cavity, including gynecology and family planning work, commonly used surgery has a variety of intravaginal minor surgery, such as gynecological commonly used physical treatment of cervical erosion - - laser, electrocautery, freezing, microwave, infrared, ohmic wave, etc., cervical dilatation, uterine cavity measurement, various curettage - diagnostic curettage, segmental curettage, uterine submucosal myomectomy, hysteroscopy , uterine tubal iodine angiography, endometrial electrical stenosis, endometrial ablation and other intrauterine operations, artificial abortion involved in family planning work, curettage after medical abortion, placement and removal of intrauterine devices, palace Internal IUD exploration, artificial insemination in assisted reproductive technology, intrauterine transplantation, ovarian puncture and egg retrieval through the posterior vagina, reduction of fetal surgery, vaginal posterior iliac puncture, and gynecological common uterus Total resection, extensive resection, etc., if there is a candida infection in the vagina, it will affect the operation as scheduled, and then surgery after surgery, often due to Inappropriate timing and affect the timely treatment, so in order to reduce postoperative complications, strict surgical indications, gynecological surgery, family planning surgery and assisted reproductive surgery should be routinely used for vaginal secretion detection of Candida and/or Mixed infections, and the use of fast and effective anti-fungal treatment, and then timely surgery is appropriate.
Complication
Recurrent vulvovaginal candidiasis complications Complications, condyloma acuminata
Mixed infections of other pathogens and other sexually transmitted diseases such as AIDS, genital warts, gonorrhea and non-gonococcal vaginitis are easily associated with Candida infection.
Symptom
Symptoms of recurrent vulvovaginal candidiasis common symptoms vulvar leukoplakia pruritus urinary rash vaginal discharge eczema frequent
Candida vulvovaginitis is mainly characterized by genital itching, burning pain, severe restlessness, abnormal pain, often accompanied by frequent urination, urgency and sexual pain.
After recurrent vulvovaginal candidiasis, symptoms, signs, and fungi are eliminated, and then reappeared, and 4 times within one year.
In the acute phase, the leucorrhea increases. The leucorrhea is characterized by thick white curd or bean dregs. If there is vulvitis, the vulva can be clearly defined with erythema, and around the large erythema, small satellite lesions can be seen, sometimes visible in the genital area. Scratches or cleft palate skin, but also secretions are odorless and yellow-white. When the environment is warm, such as when the bed or air circulation is limited, or when the patient wears tights or synthetic fabric, the symptoms will be aggravated.
Vaginal mucosa can be seen with varying degrees of edema, erythema, erythema can continue to the outer cervix, vaginal secretions often stick to the vaginal wall, when the blocky secretions are erased to reveal red and swollen mucosal surface, visible in the acute phase There are damaged erosion surfaces and superficial ulcers under the white mass.
Sometimes there are small nodules and blisters on the edge of inflammation. If the surrounding large tissues are involved, it can be seen that the infected area is dry scaly, with clear edges (eczema-like changes), and scratches and ulcers often have scratches.
The severity of the symptoms depends on the genus and strain of the infected bacteria and the susceptibility of the patient. The mild symptoms may only be mild itching without other clinical symptoms. Candida vulvovaginitis is different from other infected bacteria, and yeast does not follow the cervix. The tube rises and therefore does not cause a secondary condition associated with Candida migration. Candida infection often occurs in the late luteal phase of the ovulation cycle, ie within 1 week before menstruation.
The clinical features of Candida albicans vulvovaginitis during pregnancy are vaginal secretions. In almost all cases, there are severe genital itching, often accompanied by genital burning, and even vaginal pain and irritation. The typical secretion is cheese liquid. Like, the labia minora has edema, erythema, vaginal congestion and often with a white membrane, peeling off the white membrane, can reveal red and swollen mucosal surface, in the acute phase can see erosion surface or superficial ulcer.
The symptoms and signs of Candida vulvovaginitis are not different from those of adults, but leukoplakia or patterns are often seen.
Examine
Examination of recurrent vulvovaginal candidiasis
1. The direct examination method is the most commonly used test method in clinical practice. The positive detection rate is 60%, and its advantage is simple and fast.
(1) saline method: take a small amount of vulvovaginal secretions, apply to the slide on the slide, add 1 to 2 drops of physiological saline to reconcile.
(2) Potassium hydroxide method: Take a little curd-like secretion and place it on a slide containing 10% KOH or saline. After mixing, find spores and pseudohyphae under the microscope. Because 10% KOH can dissolve other cellular components. The detection rate of Candida was higher than that of normal saline. The positive rate of asymptomatic settlers was 10%, while the positive rate of symptomatic vaginitis was 70%-80%.
2. Gram staining method The positive detection rate of this method is 80%. The secretion smear is taken. After fixation, Gram staining is performed. Under the microscope, the ovarian spores and pseudohyphae positive for Gram staining can be seen. .
3. The culture method is suspected to be Candida vaginitis. It is negative for multiple examinations. It can be used for fungal culture. The specimens are inoculated on Sha's medium and placed in a 37 °C incubator. After 24 to 28 hours, it can be seen. A large number of small and white colonies are taken for microscopic examination. The positive rate of culture can reach 100%. The culture of Candida is mainly to observe the colony morphology, color, odor and performance under the microscope. The culture plate is sufficient to distinguish yeast cells, pseudomycelium and protoplasts, and further biochemical methods can be used to detect the consumption of sugar, nitrogen compounds and vitamins to distinguish different species.
Usually, if the patient has typical clinical manifestations and the spores and pseudohyphae are seen under the microscope, the diagnosis can be made without further cultivation to reduce unnecessary related expenses, but because the microscopy is not a A very sensitive method, so it is often necessary to make fungal culture to confirm the diagnosis.
4. Identification of strains If it is necessary to determine the type of Candida, the fermentation test, assimilation test, and identification of the colony morphology characteristics must be carried out.
5. The pH value has important discriminating significance. If the pH value is <4.5, it may be a simple Candida infection. If the pH value is >4.5, and there are many white blood cells in the smear, there may be mixed infection.
6. For elderly patients with obesity or long-term treatment, urine sugar and blood sugar should be checked to find the cause.
Diagnosis
Diagnosis and diagnosis of recurrent vulvovaginal candidiasis
Diagnostic criteria
Typical cases are not difficult to diagnose, and are easily diagnosed based on relevant medical history, predisposing factors, symptoms, signs, and laboratory diagnosis.
Asymptomatic vaginal colonization and symptomatic vulvovaginitis have no difference in the characteristics of pathogens and pathogens. Because Candida often only sees spores in asymptomatic vaginal colonies and rarely sees hyphae, it is in symptomatic patients. The diagnosis of Candida vulvovaginitis can be made by finding spores and hyphae in the secretions. The diagnostic procedure for the candida vulvovaginitis in the laboratory can be represented by the following diagram (Fig. 2).
The vaginal pH of Candida vulvovaginitis is usually <4.5. If the vaginal pH is >4.5, there are more cells in the background of the smear, suggesting mixed infection, often combined with bacterial vaginosis, trichomonas vaginitis, etc. The pH should be measured after treatment. Only the vaginal pH value returns to the normal state of the woman, and the symptoms disappear. The vaginal smear test (-) can be regarded as a real cure. If the symptoms disappear, the leucorrhea smear test (-), If the vaginal pH does not return to normal women (pH 4), it is still prone to recurrence.
Differential diagnosis
Candida vulvovaginitis often coexists before or after skin diseases. There are similarities. The biological characteristics of Candida albicans are mannose on the outside, which tends to adhere to the scaly scaly epithelium, but it is difficult to adhere to. The keratinized tissue of the vulva, so the healthy vulva skin has an anti-infective barrier. When contact dermatitis, allergic dermatitis, sclerosing moss or intraepithelial neoplasia, Candida adheres to the abnormal epithelial surface and causes Candida vulvovaginal Inflammation, genital itching, burning pain, local congestion, skin lesions, or treatment failure, think of candida vulvovaginitis, and whether there are other skin diseases, whether it is recurrent vulvovaginal candidiasis.
