Diagnosis of Vulvovaginal Can... Video Transcript

Participants

Gloria Bachmann MD, Sharon L. Hillier Ph.D., Andrea Rapkin MD, Jack D. Sobel MD, David E. Soper MD

Summary

The first step in effective treatment for vulvovaginal candidiasis is correct diagnosis to rule out bacterial vaginitis and establish species of yeast. This will include a pelvic exam, 10% KOH wet prep, pH testing, microscopy and yeast cultures.

Webcast Transcript

ANNOUNCER: Vulvovaginal candidiasis affects approximately 75% of women at some point during their lives and can be a recurrent problem for many women. The first step in effective treatment is correct diagnosis.

ANDREA RAPKIN, MD: When a patient comes in complaining of vaginal infections, it's very important to perform a thorough diagnostic workup. One of the things that is important, obviously, is the examination, so inspection of the labia, the external genitalia, the vagina, and then, of course, the evaluation of a wet prep, which would include a saline and a 10% KOH prep. The whiff test, smelling the slide after the KOH is applied, for a fishy odor, suggesting a release of amines, and the pH testing should all be done routinely.

JACK SOBEL, MD: The importance of the microscopy is not only in identifying the presence or absence of yeast, but very often gives you insight immediately into the possibility of having a non-Candida albicans species causing the Candida vaginitis, where, based on the morphology, you see budding yeast but do not see hyphae. Similarly, in performing the saline microscopy, you can identify mixed infections, Candida plus bacterial vaginosis, plus it gives a practitioner an immediate picture of the vaginal health with regard to the vaginal bacterial flora.

DAVID SOPER, MD: I think maybe a key issue here for practicing clinicians is the value of pH. If you do a pH and it's normal, it's less than 4.5, it makes you a better microscopist, because you can go to the microscope and predict that you're not going to see BV, and you're most likely going to see vaginal candidiasis.

ANNOUNCER: Another diagnostic tool is the yeast culture. But under what circumstances should clinicians use this test?

JACK SOBEL, MD: In general, if you don't have a diagnosis, you owe it to your patients to do a culture, and by culture I mean a yeast culture, and only a yeast culture. You're not asking for a bacterial culture, you're not asking for chlamydia cultures. You're not asking for GC cultures. These entities are uncommon causes of vulvitis or vulvovaginitis.

DAVID SOPER, MD: In the patient that has symptoms of vaginal yeast in whom you've done microscopy of the vaginal secretions and you do not see fungal elements, and their pH is normal, those patients really should have a vaginal yeast culture. The reason is because probably as much as 50% or more of those patients do not have yeast vaginitis, but may have an allergic vaginitis or another cause of their vaginal symptoms.

SHARON HILLIER, PhD: The best way for a physician to order a yeast culture if he wants to rule out yeast is to order a rule-out yeast culture, and not a longer fungal culture. Many times I hear from clinicians, &I ordered a yeast culture, but it took a whole month,& and that's because it was a fungal culture. Those are held for slower-growing dermatophytes, the ones that cause skin infections and athlete's foot. For yeast vaginitis, we only need to really look for Candida, and those can be finished in a day or two. So a rule-out yeast culture will cost less and get you a faster answer.

ANNOUNCER: However, with over-the-counter treatments readily available, patients have the liberty of trying to diagnosis and treat their own infections. But how effective is self-diagnosis and treatment?

DAVID SOPER, MD: There is some new information about self-diagnosis, and it's actually quite alarming. What we know is that patients are actually very poor at diagnosing their own infections. We also know that doctors over the phone or nurses over the phone are also unreliable in their ability to accurately diagnose the cause of lower genital tract symptoms.