1054
U N I T 1 1
Genitourinary and Reproductive Function
Vaginal Infections
Candidiasis, trichomoniasis, and bacterial vaginosis are
vaginal infections that can be associated with sexual
activity. Trichomoniasis is the only form of vaginitis that
is known to be sexually transmitted and requires part-
ner treatment. A male partner usually is asymptomatic.
Candidiasis
Vulvovaginal candidiasis, also referred to as a
yeast infec
tion
,
thrush
, or
moniliasis
, is one of the most frequent
reasons that women visit a health care provider.
Candida
albicans
is the most commonly identified organism in
vaginal yeast infections, but other
Candida
species, such
as
Candida glabrata
and
Candida tropicalis
, may also
be present.
16–18
These organisms are present in 20% to
55% of healthy women without causing symptoms,
and alteration of the host vaginal environment usually
is necessary before the organism can cause pathologic
effects.
18
Although vulvovaginal candidiasis usually is
not transmitted sexually, it is included in the CDC STI
treatment guidelines because it often is diagnosed in
women being evaluated for STIs. The possibility of sex-
ual transmission has been recognized for many years;
however, candidiasis requires a favorable environment
for growth of the organism. Studies have documented
the presence of
Candida
on the penis of male partners
of women with vulvovaginal candidiasis, but few men
develop balanoposthitis that requires treatment.
18
The
gastrointestinal tract also serves as a reservoir for this
organism, and candidiasis can develop through autoin-
oculation in women who are not sexually active.
Reported risk factors for the overgrowth of
C. albicans
include recent antibiotic therapy, which suppresses the
normal protective bacterial flora; high hormone levels
owing to pregnancy or the use of oral contraceptives,
which cause an increase in vaginal glycogen stores; and
uncontrolled diabetes mellitus, HIV infection, or other
diseases, which compromise the immune system.
16–18
Women with vulvovaginal candidiasis commonly com-
plain of vulvovaginal pruritus accompanied by irrita-
tion, erythema, swelling, dysuria, and dyspareunia.
The characteristic discharge, when present, is usually
thick, white, and odorless. In obese persons,
Candida
may grow in skin folds underneath the breast tissue, the
abdominal flap, and the inguinal folds.
Accurate diagnosis ismade by identification of budding
yeast filaments (i.e., hyphae) or spores on a wet-mount
slide using 10% potassium hydroxide (Fig. 41-3A). The
pH of the discharge, which is checked with litmus paper,
typically is less than 4.5. When the wet-mount technique
is negative but the clinical manifestations are suggestive
of candidiasis, a culture may be necessary.
For treatment purposes, vulvovaginitis is commonly
classified as uncomplicated or complicated. Current
choice of therapeutic agents is for the most part limited
to the azole medications, fungistatic drugs that inhibit
cell wall metabolism. Some of these antifungal medica-
tions (e.g., clotrimazole, micronazole) are available as
topical preparations (creams or suppositories) that can
be obtained without a prescription for treatment in
women with uncomplicated cases of candidiasis. Topical
terconazole and oral fluconazole are also available with
prescription. Because of ease of use, oral fluconazole
has become a preferred method for most women, but
■■
Genital warts (condylomata acuminata) are
caused by the human papillomavirus (HPV) that
infects epithelial cells. Of particular concern is
the relation between HPV infections and the
development of genital neoplasms. Over 100
types of HPV have been identified, including
subtypes 6 and 11, which are typically associated
with genital warts, and subtypes 16 and 18, which
account for approximately two thirds of cervical
dysplasia and cervical cancer.
■■
Genital herpes is an ulcerative disorder caused
by the highly contagious herpes simplex virus
(HSV). Both HSV-1 and HSV-2 are neurotrophic
viruses that produce acute primary infections
and latent recurrent episodes. During the
primary infection, the HSV ascends through
peripheral nerves to a sacral dorsal root ganglia.
Recurrences occur when the virus is reactivated
and travels down the nerve root to the affected
area.There is no permanent cure for herpes
infections.
■■
Chancroid and lymphogranuloma venereum
(LGV) produce external genital lesions with
various degrees of inguinal lymph node
involvement.These diseases are uncommon in
the United States.
SUMMARY CONCEPTS
(continued)
A
B
C
FIGURE 41-3.
Organisms that cause vaginal infections.
(A)
Candida albicans (blastospores and pseudohyphae);
(B,C)
Trichomonas vaginalis.
