For some patients presenting to the pelvic rehabilitation provider, vaginal yeast infections related to Candida are an ongoing issue, a prior causative factor in pelvic muscle tension, or a potential perpetuating issue in a patient's pelvic dysfunction. A recent research article discussing candida as a chronic disease aims to propose a definition of and diagnostic criteria for women who have chronic vulvovaginal candidiasis (CVVC). This was a prospective study involving 50 women presumed to have CVVC and 42 controls. Women with CVVC were found to have the following characteristics when compared to the control group: history of a positive vaginal Candida swab, discharge, dyspareunia, soreness, swelling, cyclicity, and worsening of symptoms with antibiotics. The authors proposed that CVVC diagnosis can be made confidently utilizing 5 or more of the following: soreness, dyspareunia, positive vaginal swab (current or past prior response to antifungal medication, exacerbation with antibiotics, cyclicity, swelling, and discharge.
The authors stated reasons for wanting to categorizing and address this issue is that they had frequently observed patients with vulvovaginal candidiasis who did not present with acute or recurrent episodes, but rather with a continuous issue. The symptoms in this population tend to improve during menstruation and ease with antifungal therapy. An interesting observation made in this article is that vaginal swab test may be negative even in the presence of other symptoms. There are several proposed theories as to why patients with chronic VVC may not have positive cultures (which is required for a diagnosis of acute or recurrent VVC) including that a woman may have treated herself with anti fungal medication prior to testing, that CVVC is a hypersensitivity reaction, or that bowel Candida is what sets off the vaginal reaction. The authors also assert that a complaint of itching is not in and of itself a sensitive marker that should be used for diagnosing any type of VVC.
With issues of high cost and self-medication available over the counter (often used without proper diagnosis awareness of symptom differentiation can be useful in the pelvic rehabilitation environment. If a patient is self-medicating with topical vaginal anti fungal medication, yet presents with symptoms more consistent with chronic vulvovaginal candidiasis, the article asserts that oral medications (a daily dose for up to or more than 6 months rather than a weekly dose) is less likely to cause irritation to the involved tissues, is less expensive, and is more effective.
The diagnostic criteria used in the study for CVVC is that a patient would need to have one major and 5 minor criteria, while a presumptive diagnosis would require 1 major and 3-4 minor criteria. Major criteria includes having chronic, nonerosive, nonspecific vulvovaginitis. Minor criteria includes positive vaginal swab (present or prior soreness, cyclicity, dyspareunia, prior positive response to anti fungal therapy, worsening with antibiotics, swelling, and discharge. While medical providers are left to diagnose and prescribe the appropriate medical treatment, pelvic rehabilitation providers are able to ask appropriate questions and communicate with the patient and provider(s) about suspected symptoms and concerns. Awareness of varying causes of vaginal soreness, skin irritation, and chronic VVC adds to our level of expertise in directing patients towards efficient healing.
Chronic vulvar pain and differential diagnosis are topics covered in our Pelvic Floor Series Level 3 class. Fortunately, if you sign up quickly you may still catch one of the remaining seats in our San Diego PF3 at the end of this month!