Candida vaginitis.

Candida vaginitis Other than the dermatophytic mycoses, Candida vaginitis is the most common fungal disease in the United Kingdom, described by Morton and Rashid (1977) as a near epidemic. Almost all the known facts about it are enumerative or descriptive and little is known of the factors affecting the pathogenesis, recrudescence, or recurrence of the mycosis. The facts do not disclose the psychological effect of this apparently minor disease on the women, their consorts and their children (Hurley, 1975). The complacency with which the treatment of the disease has been regarded until recently has not been helpful. Reported cure rates of 95% or more are comforting to the practitioner, but tend to derogate the sufferings of those countless uncured or partially cured women, who are seen as a class of medical freaks. Intractable thrush, like intractable pruritus ani, a disorder with which it has much in common, is not a condition likely to bring a happy smile to the lips of the examining physician, as he and his patient contemplate the failure of therapy. The majority of the many preparations that can be used have been considered by Odds (1977). There is no very precise information on the frequency of the intractable form of Candida vaginitis, but a retrospective study of patients treated during pregnancy in 1973 showed that 45% had had more than one course of therapy; one patient had had 9 courses. This suggests that during pregnancy, Candida vaginitis is less amenable to therapy than overall cure rates suggest. Candida vaginitis occurring during pregnancy seems to be the initiating event in many cases of inveterate vaginal thrush (Hurley, 1975). No prospective studies have been made to establish or to dispute the oft-asserted view that the condition clears spontaneously after confinement. This assumption is unwarranted, for the evidence relates only to the isolation rate of yeasts, including C. albicans, from the vagina (Jennison, 1966; Hurley and Stanley, 1972) which falls markedly in the puerperium, some think owing to the cleansing action of the lochia. There is no work to show that symptoms do not recur once the puerperium is over, but a prospective study might resolve this point. Should symptoms recur once the inoculum size has again built up, specific antifungal therapy after delivery in women selected appropriately might avert further episodes. Prophylactic antifungal therapy has been used to avert oral thrush in susceptible infants, that is those born to women harbouring C. albicans in the vagina; such children have a 35 times greater chance of developing thrush than have other newborns (Woodruff and Hesseltine, 1938). A similar approach to the prevention of long-standing Candida vaginitis might be worth considering. The ultimate source of infection by C. albicans in man is the maternal vagina. Although it is not fashionable to speak of vertical transmission with respect to colonizing fungi, there is no doubt that many infants are colonized during passage through the birth canal. Some, particularly those who are debilitated, or whose buccal mucosa has been damaged (Delafond, 1858) develop oral thrush, but most are unscathed, presumably becoming permanent carriers of the fungus in the gastrointestinal tract. Horizontal transmission occurs also, for C. albicans is a fungus that can be isolated from man and from his immediate environment. In the Paris hospitals of the last century, thrush achieved epidemic proportions, and does so still in institutions where rigorous standards of hygiene, asepsis and antisepsis are not practised. The incidence of carriage of the fungus in the gastrointestinal tract (faeces) varies from 10 to 70 %, and in the mouth from 6 to 53% (Winner and Hurley, 1964). The gastrointestinal tracts of man and birds are the chief reservoirs of C. albicans in nature (Hurley, 1967). Doubtless, the vagina is often contaminated from the perineum, but vaginal thrush, although recorded from virgins (Mettenheimer, 1880) is unusual in them, and probably minor trauma such as may be occasioned by sexual intercourse, together with a substantial inoculum of the fungus, is required to initiate infection. Experimentally, Candida vaginitis is far more readily produced in the pregnant than in the non-pregnant