Candidiasis: vulvovaginal, balanitis and complete clinical management

Learning objectives

• Distinguish uncomplicated, severe, recurrent, complicated and non-albicans VVC.
• Recognise male balanitis, oral disease and invasive candidiasis.
• Use pH, microscopy, culture/NAAT and clinical findings to establish diagnosis.
• Select safe treatment in pregnancy, diabetes, HIV and recurrent disease.
• Counsel patients about partner care, hygiene, recurrence prevention and when to refer.

Organism and predisposition

Candida is part of normal mucosal flora in many people. Disease follows altered vaginal ecology, increased oestrogen, antibiotic exposure, diabetes, pregnancy, HIV or immunosuppression. Most VVC is C. albicans; C. glabrata and other non-albicans species are less susceptible to standard azoles and are common in recurrent disease. VVC is not proof of partner infidelity or poor hygiene.

Clinical features

Vulvovaginal candidiasis

Intense vulval itch, soreness, burning, dyspareunia, dysuria from external inflammation and thick white, usually non-offensive discharge are typical. Examination may show erythema, oedema, excoriations and fissures. The discharge is not always clumpy, and absence of odour does not prove candidiasis.

Male candidal balanitis

Itching, burning, erythematous glans, small papules, moist patches and fissuring may occur, particularly with diabetes, antibiotics or a partner with symptoms. Recurrent balanitis warrants diabetes testing and assessment for phimosis or dermatoses.

Oral and oesophageal disease

Creamy plaques that scrape away leaving an erythematous base, angular cheilitis, sore mouth or odynophagia suggest mucosal candidiasis. Oesophageal symptoms require systemic therapy and assessment for HIV or other immunosuppression.

Invasive candidiasis

Persistent fever or sepsis, central-line exposure, abdominal surgery, neutropenia or prolonged antibiotics raise concern for candidemia. This is not managed with topical vaginal medication.

History and examination

1. Ask about onset, recurrence count, pregnancy, menstrual relation, antibiotics, diabetes, HIV, steroids, contraception and prior treatments.
2. Clarify odour, colour, pelvic pain, fever, bleeding, urinary symptoms, dyspareunia and STI exposure.
3. Inspect vulva, vagina, cervix, penis and oral mucosa; assess for ulcers, vesicles, cervical motion tenderness or dermatoses.
4. Check glucose/HbA1c, HIV status and medication interactions when disease is recurrent or complicated.

Diagnosis

• Vaginal pH is usually normal (<4.5) in VVC; a higher pH suggests bacterial vaginosis or trichomoniasis, though mixed infection can occur.
• Wet mount with saline and KOH may show budding yeast or pseudohyphae; a negative microscopy does not exclude disease.
• Culture or validated NAAT is recommended for recurrent, severe, persistent or non-albicans disease and before prolonged suppression.
• Do not treat asymptomatic colonisation except in specific specialist situations; a positive culture must match symptoms and examination.
• Consider gonorrhoea, chlamydia, trichomoniasis, bacterial vaginosis, genital herpes, contact dermatitis, lichen sclerosus and desquamative inflammatory vaginitis.

Management

Partner care and sexual health

Routine treatment of an asymptomatic male partner is not recommended for uncomplicated VVC. Symptomatic balanitis should be examined and treated with appropriate topical therapy, while recurrent couple-associated symptoms may justify assessment of both partners. Advise abstinence or condoms until pain and inflammation settle. Screen for other STIs when history or examination indicates risk; candidiasis alone does not establish an STI.

Prevention and self-care

• Avoid unnecessary antibiotics and scented vaginal products, douching and harsh soaps.
• Keep the area dry, use breathable underwear and change out of wet clothing.
• Optimise glycaemic control and HIV treatment; do not rely on probiotics as a substitute for therapy.
• Explain medication adherence and avoid stopping treatment as soon as itch improves in recurrent disease.
• Seek review for fever, pelvic pain, ulcers, pregnancy, recurrent episodes or failure after treatment.

When candidiasis is not the answer

Fishy odour, thin grey discharge and clue cells suggest bacterial vaginosis. Frothy yellow-green discharge and strawberry cervix suggest trichomoniasis. Vesicles or painful ulcers suggest herpes. Cervical motion tenderness, fever or lower abdominal pain raises PID. Vulval fissures, white plaques or architectural change may indicate dermatosis and require specialist assessment.

Invasive candidiasis red flags

Hospitalised patients with fever or shock, central venous catheters, recent abdominal surgery, neutropenia, renal replacement therapy or persistent candidemia require blood cultures, source control, systemic antifungal treatment and evaluation for metastatic infection. Obtain ophthalmic and cardiac assessments according to current local protocol. Vaginal treatment is never adequate for candidemia.

Exam pearls

• VVC usually has normal vaginal pH; BV and trichomoniasis usually raise it.
• Recurrent VVC requires culture/speciation and evaluation for diabetes or immunosuppression.
• Topical azoles are preferred in pregnancy; avoid routine oral fluconazole.
• Asymptomatic Candida colonisation does not automatically require treatment.
• Persistent symptoms after treatment demand a new diagnosis, not automatic retreatment.

References

• SlideShare: Candidiasis.
• Uganda Clinical Guidelines: Candidiasis.
• WHO/CDC guidance for vulvovaginal and invasive candidiasis.

Safety note: Verify current Uganda regimens, pregnancy restrictions, drug interactions and referral criteria before prescribing.