GENITAL INFECTION

There are many types of genital infection is including with sexual transmitted disease. The
common of genital infection and STD are vulvovaginal candidiasis and syphilis (STD). Detail of
these disease as below:

INTRODUCTION VULVOVAGINAL CANDIDIASIS

Vulvovaginal candidiasis (VVC) is a second common genital infection cases (70%) and also
known as vaginal candidiasis, yeast infection, and genital candidiasis. The fungus most
commonly that caused VVC is called Candida albicans, (>92%) and can be found on warm and
moist area of the body. This disease is common in all women, but may occur more frequently
and more severely in immunocompromised women.

PATHOPHYSIOLOGY OF VULVOVAGINAL CANDIASIS

The normal vaginal epithelium cornifies which is a thickened layer of epithelial cells and
develop under the influence of estrogen and have function in protecting women against infection.
A normal vaginal discharge consists of 1-4 mL of fluid that is white or transparent, thick, and
odorless. This physiologic discharge is formed by sloughing epithelial cells, normal bacteria, and
vaginal transudate. The discharge may be noticeable during pregnancy, oral contraceptive pill
use, or at mid menstrual cycle, close to the time of ovulation. The normal pH of vaginal
secretions is 4.0 until 4.5. This pH is maintained by lactobacillus (produces hydrogen peroxide
and lactic acid), diphtheroids, and Staphylococcus epidermidis. Lactobacillus is found in 62-88%
of women. Vaginal pH may increase with age, phase of menstrual cycle, sexual activity,
contraception choice, pregnancy, presence of necrotic tissue or foreign bodies, and use of
hygienic products or antibiotics (Mark J Leber, 2009; Anuritha Tirumani, 2009)

TYPES OF VULVOVAGINAL CANDIDIASIS

There are two types of VVC which including uncomplicated VVC and complicated VVC.
Uncomplicated VVC is sporadic or infrequent VVC. It is mild or moderate VVC, albican
candidiasis and normally it is given infection to nonimmunocompromised women. Other types of
VVC are complete VVC or also known as recurrent or chronic VVC (RVVC). This kind of VVC
is severe VVC and categorized to nonalbicans candidiasis. RVVC usually defined as four or
more episodes of symptomatic VVC in 1 year, affects a small percentage of women (<5%). The
pathogenesis of RVVC is poorly understood, and the majority of women with RVVC have no
apparent predisposing or underlying conditions. Vaginal cultures should be obtained from
patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including
nonalbicans species, particularly Candida glabrata. Usually, women with uncontrolled diabetes,
debilitation, or are immunosuppression, or those who are pregnant tend to get this kind of
infection. (Armen Hareyan, 2004)

ASSESSMENT OF VULVAVAGINAL CANDIDIASIS

Normally, when patient came with VVC, they will be ask about past history of sexual intercous,
characteristic of vaginal discharge, source of infection, past history of gynecologic problem or
other symptoms (Silvia Abularach, Jean Anderson, 2005) Besides that patient will be ask about
medical history such:

• Type and duration of symptoms • Diabetes history

• Previous vaginal yeast infection • Cushing syndrome

• Oral contraceptive use • Obesity

• Recent or ongoing broad-spectrum • Hypothyroidism

antibiotic therapy
• Pregnancy
• Recent corticosteroid therapy
• Use of douches, vaginal deodorants,
• Sexual exposures (to evaluate for or bath additives
sexually transmitted infections)

While, in physical examination, we will inspect type and color of discharge, level of pain, the
present of tenderness or mass. We also need check of vital signs because VVC always associate
with fever. (Clin Evid. 2004)
CLINICAL MENIFESTATION OF VULVOVAGINAL CANDIDIASIS

Symptoms of VVC can be identified by doing physical examination on patient. Symptoms of

superficial site of mucosa which is at vaginal mucosa, we can found white or yellow discharge,
with pruritus and local excoriation. We also can see white or gray raised patches on vaginal
walls, with local inflammation and dyspareunia. If there is involved with systemic infection, it
will produces chills with high spiking fever, hypotension, prostration, myalgias, arthralgias,
and a rash. Besides that patient will feel intensely itching of the genitals part with painful or
burning urination, and painful intercourse.

CAUSES/ETIOLOGY OF VULVOVAGINAL CANDIDIASIS

There are many types of causes that can lead to VVC. The cause of infection during
premenarchal period is because of poor perineal hygiene, chemical irritants such as bubble baths
and lotions. Other than that, it may causes by present of vaginal foreign bodies or by infection of
pinworm, GABHS and also by skin conditions such as Eczema, psoriasis, and seborrhea. Besides
that, etiologies also usually associated with women of childbearing age. These etiologies
including sexual contact especially with multiple sexual contacts, no method of birth control,
history of STD, infections by bacterial or fungal such as G vaginalis (bacterial vaginosis),
Candida species, and Trichomonas species and chemical irritants. In addition, recent broad-
spectrum antibiotics such as tetracycline, ampicillin, and cephalosporins and pregnancy also can
cause VVC. Atrophic vaginitis is most common cause of vulvovaginitis in postmenarchal
women.( Dr Amanda Oakley, 1997)

TREATMENT OF VULVOVAGINAL CANDIDIASIS

Medical treatment

Normally patient with VVC treat by given medication which is including antifungal vaginal
medications (creams, tablets and suppositories). The optimal treatment for recurrent
vulvovaginal candidiasis has not yet been defined (Dr Amanda Oakley, 1997). But there are
some drug used to treat RVVC such as:
Topical Azoles
• Butoconazole 2% cream 5 g PV for 3 days* 100-mg tablets administered intravaginally for
seven days
• Butoconazole 2% cream 5 g (sustained release) One full applicator (5 g) administered
PV application x 1 intravaginally for three days†
• Clotrimazole 1% cream 5 g PV for 7–14 days* 150 mg administered orally (one dose)

• Clotrimazole 100 mg vaginal tablet for 7 days 200 mg administered orally once daily for 14 days
• Clotrimazole 100 mg vaginal tablet, 2 tablets for
3 days 400 mg administered orally once daily for 14 days

• Clotrimazole 500 mg vaginal tablet x 1 600-mg vaginal suppository administered twice

daily for 14 days
• Miconazole 2% cream 5 g PV for 7 days*
• Miconazole 200 mg vaginal suppository for 3 Two 100-mg tablets administered intravaginally
days* twice weekly for six months
• Miconazole 100 mg vaginal suppository for 7 Two 200-mg tablets administered orally for five
days* days after the menses for six months
• Tioconazole 6.5% ointment 5 g PV x 1* One half of a 200-mg tablet administered orally
once daily for six months
• Terconazole 0.4% cream 5 g PV for 7 days One full applicator (5 g) administered vaginally
once a week†
• Terconazole 0.8% cream 5 g PV for 3 days 150 mg administered orally once a month

• Terconazole 80 mg vaginal suppository for 3 One 200-mg tablet administered orally once a
days month
• * Available over the counter. Two 200-mg tablets administered orally once a
PV, vaginally. month
Note: These creams are oil-based and may
weaken latex condoms and diaphragms.
Oral agent† 600-mg vaginal suppository administered once
daily during menstruation (5-day menses)
• Fluconazole 150 mg po x 1

(source:CDC 2002)
Other treatment

1. Vinegar douches. Douching may remove healthy bacteria that line the vagina but this not
encourage by doctor because douching may worsen the condition.
2. Eating yogurt that contains live acidophilus cultures (or eating acidophilus capsules):
3. Used antihistamines or topical anesthetics:
(Am Fam Physician, 2000)
INVESTIGATION OF VULVOVAGINAL CANDIDIASIS
Normally, investigation that doing for VCC patients are physical and pelvic examination, test of
women’s urine and samples of vaginal discharges. Before the exam, sexual intercourse and
douching should be avoided for one to two days to avoid complicating the diagnosis. During the
pelvic examination, inspection on the woman's vaginal canal and cervix for discharge, sores, and
any local pain or tenderness will be done. Speculum will be inserted into the vagina to examine
the cervix. This may be uncomfortable because of pressure on the vaginal tissues. Besides that,
the culture swabs of any vaginal discharge to determine if the infection is fungal (yeast),
protozoan (trichomoniasis), or bacterial (bacterial vaginosis) by viewing discharge sample under
a microscope to look for organisms that cause vaginal yeast infections. In some cases, a Pap test
will be doing to rule out the possibility of cervical dysplasia or cancer. The test is then sent to a
laboratory, and results typically take one week. Patient may undergo a colposcopy or biopsy if
the woman's cervix appears abnormal. Colposcopy involves a lighted microscope to examine the
surface of the cervix. A biopsy involves taking a tissue sample for testing. The doctor also may
use a blood test to assess for antibodies associated with Candida albicans. This test is normally
used only to determine a widespread (systemic) infection has developed. (Brian Acacio, 2010)

OBJECTIVE OF VULVOVAGINAL CANDIDIASIS CARE

 To reduce complication that can be come out from VVC problem
 To help patient with VVC making self-care when they at home
 To provide information about vulvuvaginal candidiasis, so that they can understand about
the diseases
 To reduce risk for infection to not infected VVC patient by teaching them proper self-
care.
 To reduce pain or suffer that patient facing.

NURSING DIAGNOSIS

N Nursing Goal Intervention Rational

o. diagnosis
1 High risk for Patient able Obtain a history of the patient’s
infection related to reduced presenting symptoms:
to exposure to risk of • Pain (duration, intensity,
pathogen infection. location, character)
• Urinary symptoms (dysuria,
urgency, frequency,
frequency)
• Pruritis (location, intensity,
duration)
• Dyspareunia
• Vaginal discharge (duration,
color, amount, odor)
• Genital lesions (location,
color, size, exadute, pain)
Obtain a sexual history
• Number of sexual partners
• Contraceptive methods used
• History of any genitourinary
infections in partners
Obtain or assist with obtaining
laboratory specimens as ordered
• Cervical, vaginal, and vulvar
cultures for herpes (if indicated)
• Culture of vulvar and vaginal
lesion (if indicated)
Administer medication
prescribed
Teach the patient how to use
medication correctly, including
• Importance of completing the medication should be
entire prescription
• Importance
taking/applying/inserting
medication on time
• How to insert vaginal and apply
topical medication correctly
This provides
information as to the
acuity and extent of
the infection.
Inflammation of the
vulva and vaginal may
cause impaired tissue
integrity, which
predisposes the patient
to infection. Infection
of the lower genital
tract may predispose
the patient to pelvic
inflammatory disease.
This provides
information regarding
behavior that may
increase the risk of a
sexually transmitted
disease
as Immediate treatment
with the appropriate
antimicrobial therapy
reduces the possibility
that the infections will
spread to adjacent
tissues and will
rediced further
inflammation
The full course of
completed correctly to
of reduced the possibility
of in adequate
treatment
 Teach the patient signs and Same vaginal
symptoms VVC and instruct the discharge are
patient to call the health care associated with
provider immediately. Provide the infection of the upper
patient with the phone number for genital tract
24 hour emergency care.
Inform the patient about the need Scheduling of follow-
for the following appointments ups will depend on the
cause of the vaginitis
and the treatment.
Some infections
require test of cure to
assure adequate
treatment.
2 Pain related to Pain among Ask patient to describe her
trauma due to patient able perception of the discomfort or
scratching related to reduced. pain.
to scratching Identify what comfort measures are
being used to comfort and
determine whether these strategies
are effective
Elimination factors that may Patient may
contributes to her physical experience a decreased
discomfort during procedures ability to tolerate
(example: make sure that the discomfort if
examination room is warm enough, environmental factors
the procedure table is as are stressful
comfortable as possible with a
pillow, her bladder is empty)
Teach the patient comfort measures These strategies can
that may help her cope with the help reduce some of
discomfort (example: cool sitz the inflammation
baths, loose clothing, cotton
underwear)
3 Altered sexuality Patient able Obtain a sexual history to This provides a
pattern related to to determine pretreatment sexual baseline for care
recommendation understandin activity patterns, number of sexual planning
for abstinence g about safe partners, and safe sex practices
until the patient’s sex Provides a private environments to Most women are
symptoms have intercourse. discuss any aspect of sexual hesitant to discuss
resolved and the activities personal sexual
patient and all of matters. The proper
her sexual setting may facilitate
partners have discussion
completed Explain why sexual activity
treatment patterns need to be restricted during
 evidence by treatment
reported change Offer suggestions for activities that Restrictions on sexual
in sexual meet the couple’s need for contact activity should not
behaviors and and intimacy without having deprive the couple of
activities. other activities that
intercourse (example: hugging,
convey the message
kissing, massages) the they are loved and
desired nor should
such restrictions
deprive them of
intimate physical
contact
Reassure the patient that the
recommendation for abstinence is
temporary

Couples may find it easier to cope Discuss the role of

with restrictions if they see the sexual activity in the
restrictions as temporary transmission of
sexually transmitted
disease. Offer
information that can
help the patient
reduced her risk of
acquiring a STDs,
example: reduced the
number of sexual
partners, use condoms,
and have regular
examinations for
STDs if she is not in a
monogamous
relationship
4 Knowledge Patient able Assess patient’s knowledge of
deficit related to to increase normal reproductive anatomy and
unfamiliarity with knowledge of physiology
the causes, condition,
diagnostic treatment and Assess patient’s knowledge of the Gathering information
procedures, care cause, treatment, and prevention of facilitates
treatments, and sexually transmitted disease. development of
prevention of appropriate teaching
VVC evidence by plan.
misunderstanding
by patients. Provide the following information
• Normal reproduction anatomy
and physiology of vulvovaginitis
 • Transmission of sexually
transmitted disease (when
appropriate)
• Types of diagnostic and
therapeutic procedures (example:
pelvic examination, cultures,
specimens) and describe the
types sensations the patient will
experience during those
procedures.
• Rationale for all diagnostic,
therapeutic, and preventive
procedures.
• Instructs on the proper use of all
medication and signs and
symptoms of medication
complications
• Signs and symptoms of pelvic
inflammatory disease
• Sources of 24-hour emergency
care for the patient if she has
problem after she leaves the
office.
• Safe sex practices, including
limitation the number of sexual
partners, condom use
• Discontinue douching
Include significant others in the Written instruction
explanation or instruction if the reinforces verbal
patients desire their presence. teaching and can also
Provide written material that be shared with sexual
reinforces explanation and partners
instruction
Use audiovisual teaching resources Demonstrations are
(example: videotapes, anatomic useful for acquiring
models, demonstration) to reinforce psychomotor skills
(example: condom
explanations and instructions.
use, inserting vaginal
medications)
CONCLUSION

It is important the diagnosis of vulvovaginal candidiasis is confirmed by examination and

culture. For women with recurrent vulvovaginal candidiasis, adequate treatment for the initial
infection may involve doubling the standard treatment. Maintenance therapy can then be
commenced and continued for at least 6 months. Cure can be difficult to achieve, and a
significant proportion of women will relapse after ceasing therapy.

REFERENCES:

Belinda Sheary, Linda Dayan. Recurrent vulvovaginal candidiasis. Australian Family Physician,
March 2005; Vol. 34, No. 3

Guide to the Clinical Care of Women with HIV/AIDS, Silvia Abularach, Jean Anderson. 2005
edition. Available online at
http://hab.hrsa.gov/publications/womencare05/WG05chap6.htm#WG05chap6e

Sobel J, Faro S, Force RW, et al. Vulvovaginal candidiasis: Epidemiologic, diagnostic, and
therapeutic considerations. Am J Obstet Gynecol 1998;178:203–11.

Treatment of recurrent vulvovaginal candidiasis Am Fam Physician. 2000 Jun 1;61(11):3306-12,

3317. Available at online http://www.ncbi.nlm.nih.gov/pubmed/10865926 February 1, 2010.

Vaginal Infections, Brian Acacio, MD. March 14, 2008 Available at online
http://www.emedicinehealth.com/vaginal_infections/page5_em.htm#Exams%20and
%20Tests
Vulvovaginal Candidiasis. Armen Hareyan, Aug 11th, 2004. Available at online
http://www.emaxhealth.com/4/558.html

Vulvovaginal candidiasis. Dr Amanda Oakley. DermNet NZ. Available at online

http://dermnetnz.org/fungal/vaginal-candidiasis.html 17 Oct 2009. © 2010