Genital candidiasis

　　1. Etiology

　　Candida albicans is a conditional pathogenic bacterium. Whether it causes an infection in the human body depends on the strength of the human immune system and the quantity and virulence of the infecting bacteria. Under conditions such as pregnancy, diabetes, oral contraceptives, long-term use of broad-spectrum antibiotics, corticosteroids, and immunosuppressants, which can lower the body's immune system and change the vaginal environment, candidal infections are more likely to occur.

　　The infection of Candida albicans starts with adhering to the host's epithelial cells, and then forming an infection focus under the action of the above-mentioned pathogenic factors of Candida albicans. The adhesion to the epithelial cells is because the host cell membrane surface has the adhesion receptors of Candida albicans, namely fucose and N-acetyl glucosamine; Candida albicans has various adhesion mediators on the cell wall, among which the most important are mannoprotein complex (M-P) and chitin. Chitin is a stereospatial polymer composed of (1-3, 1-6) β-glucan and N-acetyl glucosamine compounds; the cell wall of Candida albicans has adhesion receptors containing fibronectin, fibronectin, etc. These components are widely distributed in vascular walls, inflammatory lesions, and sites of wound healing, with strong adhesion, and after adhering to Candida albicans, they can bridge the adhesion between Candida albicans and host cells, making it easier for Candida albicans to adhere to and invade the host.

　　The pathogenicity of Candida is related to the following factors: adhesion force; adhesion force is proportional to virulence, and Candida albicans has the strongest adhesion force in the genus; two morphological types: when infected, Candida albicans often presents in the hyphal form. The virulence of the hyphal form is stronger than that of the yeast form; toxins: polysaccharide toxins on the surface of the bacterial cells and another called 'candida toxin' may be factors causing disease; cell surface components; extracellular enzymes: Candida albicans can produce secret some enzymes, such as hemolytic phospholipase, phospholipase, and extracellular acidic protease (CAP), etc. Among them, CAP is the most important. CAP can hydrolyze proteins, as well as keratin and collagen, and has the function of promoting the adhesion of Candida albicans.

　　Second, Pathogenesis

　　Candida is a conditional pathogen, and the decrease in body resistance is the internal cause of onset. The virulence or pathogenicity of Candida is the external cause.

　　The balance between candidiasis, vaginal flora, and vaginal defense mechanisms determines different clinical manifestations. The risk factors for vulvovaginal candidiasis include:

　　1, Using a large amount of broad-spectrum antibiotics.

　　2, Pregnancy.

　　3, Using oral contraceptives with high estrogen content.

　　4, Diabetes.

　　5, Receiving immunosuppressive therapy and HIV infection.

　　6, Others: Wearing tight, non-breathable panties, vaginal irrigation, etc. In males, long-term changes in hormone metabolism, diabetes, long-term use of antibiotics or corticosteroids can all lead to changes in the body's immune function, causing candidal infection in the prepuce and glans penis.

　　The main cause is candidal vulvovaginitis, which is caused by the stimulation of vaginal discharge on the vulva, plus secondary infection, leading to candidal vulvitis. At this time, the labia majora, labia minora, mons pubis, and perineum, as well as the inner side of the thigh, may appear erythema, erosion, with moist white scale-like skin on the surface, and around the erythema, blood papules and small blisters may appear, with a significant sense of itching. Complicated VVC refers to recurrent vulvovaginal candidiasis, with more severe clinical symptoms, which can be caused by other candidiasis besides Candida albicans, often accompanied by diabetes, immunosuppression, or pregnancy.

　　Candidal balanoposthitis: More common in cases of phimosis, with a history of unprotected sexual intercourse, the prepuce and glans penis are slightly erythematous. White cheesy plaques may be present on the inner plate of the prepuce and the coronal sulcus of the glans. The glans can have pinpoint-sized light red papules. If the prepuce outside and the scrotum are involved, scaly erythema can be seen. If the navicular fossa is involved, there may be symptoms such as frequent urination and dysuria. Local burning sensation and itching may occur. For those allergic to Candida, pruritus and burning sensation on the penis may occur several hours after unprotected sexual intercourse, with erythema of the prepuce and glans penis, and occasionally an explosive edematous balanoposthitis may occur, mainly manifested by obvious swelling of the prepuce, severe itching, and superficial ulcers.

　　Candidal vulvovaginitis: Vaginal itching and increased leukorrhea are the prominent manifestations of this disease. Local itching, due to scratching, can cause swelling of the labia minora, skin erosion, scratch marks, and pustules. Increased vaginal discharge is sticky, cheesy, or dreg-like, with an unpleasant smell, and can be accompanied by vaginal pain, irritation, and difficulty in sexual intercourse. Examination may show a white pseudomembrane on the vaginal wall mucosa, which, upon falling off, can cause erythema or ulcerated surfaces. The vaginal wall is congested and swollen. Some asymptomatic healthy women may have Candida isolated in the vagina, but it does not necessarily cause vaginitis. Pregnancy, oral contraceptives, or antibiotics, diabetes, or wearing tight clothing can be involved.

　　1. Vulvovaginal candidiasis

　　1. Main symptoms:There is vulvar itching, burning pain, increased vaginal discharge, dysuria, pain or irritation in the vagina, and superficial sexual pain during intercourse. Vulvar itching is the most common symptom, almost seen in all symptomatic patients, with varying degrees of severity. Typical vaginal discharge is white curd-like or dreg-like, but can also be watery or uniform and thick.

　　2. Physical examination:Vulvar erythema and edema can be seen, with scattered scratch marks or skin peeling. In chronic infections, the vulvar skin becomes thickened and lichenoid. The vaginal mucosa is congested, red, swollen, or ulcerated. There are white curd-like or dreg-like secretions in the vagina, and a white film-like substance is attached to the vaginal wall. The pH value of vaginal secretions is generally normal.

　　The symptoms of VVC recur 4 times or more per year and are confirmed by pathogenicology, known as recurrent vulvovaginal candidiasis (RVVC). Approximately 5% of VVC patients can develop into RVVC. Currently, VVC is divided into two major categories: uncomplicated and complicated, based on clinical manifestations, microbiology, host factors, and response to treatment. Uncomplicated VVC refers to occasional VVC with mild to moderate symptoms, mainly caused by Candida albicans, with good immune status and effective for routine antifungal treatment. This category accounts for 90% to 95% of cases. Complicated VVC refers to recurrent vulvovaginal candidiasis, with more severe clinical symptoms, which can be caused by other Candida species besides Candida albicans, often accompanied by diabetes, immunosuppression, or pregnancy.

　　Two, candidal balanoposthitis

　　Diffuse erythema, dry and smooth, with red papules or white cheesy plaques on the inner prepuce and corona groove. When the urethral orifice navicular fossa is involved, symptoms such as frequent urination and dysuria may occur.

　　Vaginal candidiasis is one of the most common diseases of vaginal infection in women. Due to the widespread use of broad-spectrum antibiotics and corticosteroids, the incidence of the disease is increasing, becoming the main cause of increased leukorrhea.

　　Vaginal candidiasis is common in women from adolescence to pre-menopausal age. The incidence of vaginal candidiasis in young girls before the next menstrual period and post-menopausal women is relatively low. The detection rate of Candida in the vagina of asymptomatic healthy women of childbearing age is about 20%. Factors such as pregnancy, taking birth control pills, and diabetes can increase the carriage rate.

　　The detection rate of male penile candidiasis is closely related to whether the prepuce is too long. The detection rate of candidiasis in the penis of men with phimosis who have not undergone prepuce circumcision is higher than that of men who have undergone prepuce circumcision. The sexual partners of women with vaginal candidiasis have a high rate of genital candidiasis infection up to 70%, and the detection rate of candidiasis on the penis of the male partners of women with vaginal candidiasis is more than 4 times higher than that of the control group. Among women who have sexual contact with male candidiasis-positive, the incidence of candidiasis infection is 80%, while among women who have sexual contact with male candidiasis-negative, the infection rate of candidiasis is 32%. It can be seen that genital candidiasis is closely related to sexual contact, and vaginal candidiasis and candidal balanoposthitis can be spread to each other through sexual contact.

　　One, direct microscopic examination

　　Women use a longer disinfected cotton swab to take vaginal, cervical secretion, or milk white film on the vaginal wall as the specimen. Men scrape the skin scales on the surface of the prepuce, glans penis, corona groove, or prepuce for the specimen. The specimen is prepared with 10% potassium hydroxide or saline, and a large number of oval spores and pseudohyphae can be seen under the microscope. If a large number of pseudohyphae are found, it indicates that Candida is in the pathogenic stage, which is more significant for diagnosis.

　　Two, staining examination

　　Gram staining, Congo red staining, or PAS staining can also be used for staining after microscopic examination, and their positive rates are all higher than those of direct microscopic examination. Gram staining, the spores and pseudohyphae are stained blue: Congo red and PAS staining, the spores and pseudohyphae are stained red.

　　Three, isolation culture

　　For patients with negative smears, candidal culture can be performed. Under sterile conditions, the test specimen is inoculated onto Sabouraud medium (the tube method of culture is often used), a few slits are made on the slanting tube medium, 2-3 inoculations are made per tube, 2 tubes are inoculated per specimen, and the medium is incubated in a 37℃ incubator for 24-48 hours. After incubation, a large number of milky white colonies can be observed. A small amount of colonies is picked up with a loop and spread on a slide for direct microscopic examination or stained and then examined. A large number of blastospores can be seen, and a preliminary diagnosis of candidal infection can be made.

　　Four, antibodies against Candida albicans can be detected by immune double diffusion or latex agglutination method.

　　Fungal culture: Consider performing candidiasis culture and identification as well as drug sensitivity testing in the following situations:

　　1. When clinical symptoms suggest VVC but the microscopic examination is negative.

　　2. When empirical treatment for uncomplicated VVC fails.

　　3. Prepare for long-term suppressive antifungal treatment for patients with complications of VVC before treatment.

　　1. Therapeutic recipes for vulvovaginal candidiasis

　　1. Mixed fresh lotus root

　　20 grams of mung beans, 300 grams of fresh lotus root, and 3 slices of fresh mint. Wash the fresh lotus root clean and peel it, soften the mung beans in water, stuff them into the holes of the lotus root, steam and slice them, chop the fresh mint, sprinkle it on top, season it, and eat it cold.

　　2. Stewed pig intestines with mung beans

　　Pig intestines, mung beans, and Patrinia scabiosa in appropriate amounts. Boil the mung beans for 20 minutes, put them into the pig intestines (tied at both ends) and Patrinia scabiosa, and cook them together until done, then add seasonings and eat.

　　3. Kelp and mung bean soup

　　Kelp (chopped), mung beans, and sugar in appropriate amounts, cooked into soup and taken once a day, for 10 consecutive days.

　　4. Other

　　30 grams of Psoralea corylifolia, 5 red dates, decocted in water, taken twice a day.

　　2. Foods that are good for vulvovaginal candidiasis

　　1. Choose light and nutritious foods rich in vitamins A, B2, C, etc.:Such as animal liver, fish eggs, carrots; poultry eggs and fresh vegetables, such as tomatoes, spinach, amaranth, soybeans, lotus root, etc.; eat more fresh fruits, such as oranges, tangerines, pomelos, lemons, strawberries, hawthorn, hawthorn, etc.

　　2. People with vulvar itching should eat more nutritious foods:Such as chicken, milk, tofu, beans, etc.

　　3. Appropriately supplement vitamins A, B2, and folic acid:Such as fish liver oil, carrots, animal liver, fish, apricots, whole wheat, pumpkin, etc. They can alleviate itching symptoms, but should not be consumed in excess.

　　3. Foods that should not be eaten for vulvovaginal candidiasis

　　1. Stimulants:Such as sea fish, shrimp, crab, river fish, lake fish, etc., which can worsen the itching of the external genitalia after eating, so they should be avoided.

　　2. Cigarettes and alcohol:Because they can exacerbate inflammation and congestion, making vaginal itching worse, they should be avoided.

　　3. Spicy and刺激性 foods:Such as chili, pepper, fennel, Sichuan pepper, onion, etc., which can cause the inflammation to spread and increase vaginal itching, so they should be avoided.

　　4. Fried and sweet腻 foods:Such as lard, butter, butter, fried pork chop, fried beef chop, sugar candy, chocolate, etc., which have a dampening effect and are not conducive to treatment, so they should be avoided.

　　1. Traditional Chinese medicine treatment

　　Traditional Chinese medicine believes that vulvovaginal candidiasis is caused by the accumulation of damp-heat within the body, compounded by external invasion of pathogenic factors. Damp-heat is an internal factor, while toxic factors are external, and the interaction of internal and external factors leads to persistent illness. Over time, damp-heat pathogens are bound to injure the Yin, resulting in a syndrome characterized by both deficiency and excess, with symptoms of Yin injury and damp-heat obstruction. Traditional Chinese medicine pays special attention to different syndromes and different constitutions, and administers different medications. Generally speaking, vulvovaginal candidiasis is a disease characterized by symptoms such as vaginal itching and increased leukorrhea. Therefore, traditional Chinese medicine also refers to this disease as leukorrhea and vaginal itching disease. Clinically, treatment is often based on the amount, color, smell, and overall condition of leukorrhea for differential diagnosis and treatment.

　　The main manifestations of genital candidiasis due to damp-heat accumulation are vulvar itching, abundant leukorrhea resembling bean curd, often accompanied by restlessness, insomnia, epigastric and abdominal distension, red tongue with yellow greasy coating, and wiry slippery pulse. This is due to the internal accumulation of damp-heat in the patient, flowing down the meridians of the liver and gallbladder, causing damp-heat to produce parasites, and parasites eroding the vulva, leading to symptoms such as vulvar itching and abundant leukorrhea. Treatment should focus on clearing heat and promoting diuresis, and killing parasites and relieving itching. Common prescriptions include: 10g of Acorus tatarinowii, 10g of Phellodendron amurense, 20g of Poria, 10g of Atractylodes macrocephala, 10g of Plantago asiatica, 10g of Spergula, 10g of Spergularia, 10g of Sophora flavescens, 20g of Dictamnus dasycarpus, 10g of Coptis chinensis. This formula uses Acorus tatarinowii, Phellodendron amurense, Poria, Plantago asiatica, and Coptis chinensis to clear heat and remove dampness, Spergularia, Sophora flavescens, Dictamnus dasycarpus, and Coptis chinensis to kill parasites and relieve itching. If the patient has symptoms of spleen deficiency, such as poor appetite and loose stools, 30g of Dioscorea opposita, 10g of Atractylodes macrocephala, and 10g of Atractylodes alba can be added.

　　The main symptoms of genital candidiasis due to damp heat accumulation are abundant leukorrhea, yellowish or whitish in color, resembling bean curd, with an unpleasant smell, or leukorrhea mixed with blood streaks, pruritus of the vulva, even redness, swelling, ulceration, frequent urination, urgency, dysuria, uncomfortable defecation, white greasy tongue coating, and slippery pulse. This is due to the long accumulation of damp-heat evil, causing parasites and toxins. The damp-heat accumulation injures the vulva, leading to various symptoms. Treatment should focus on clearing heat and removing dampness, and detoxifying and relieving itching. Common prescriptions include: 20g of Poria, 10g of Poria cocos, 10g of Alisma orientale, 10g of Plantago asiatica, 10g of Inula japonica, 20g of Dictamnus dasycarpus, 10g of Spergula, 30g of Paris polyphylla, 10g of Chrysanthemum morifolium, 30g of Hedyotis diffusa. The formula uses Poria, Poria cocos, Alisma orientale, Plantago asiatica, and Inula japonica to clear heat and remove dampness, Dictamnus dasycarpus and Spergula to kill parasites and relieve itching, Paris polyphylla, Chrysanthemum morifolium, and Hedyotis diffusa to clear heat and detoxify. If the patient has symptoms of frequent urination, urgency, and dysuria, 10g of wood vinegar and 20g of talc can be added.

　　Secondly, the Western medical treatment methods for genital candidiasis

　　1. Drug treatment

　　(1) Vulvovaginal candidiasis (VCC)

　　Local medication is mainly used, and imidazole antifungal drugs are more effective than nystatin. After treatment with imidazole antifungal drugs, 80%-90% of patients experience symptom relief and negative candidiasis culture.

　　Wash the vulva and vagina with a 3% sodium bicarbonate solution or infuse the vagina with a 1:5000 gentian violet solution, once or twice a day.

　　Vaginal suppositories containing nystatin or imidazole antifungal drugs, such as clotrimazole, miconazole, econazole, butoconazole, one suppository each night, inserted deeply into the vagina, for 1-2 weeks.

　　Topical application of imidazole antifungal preparations can be used for vulvitis, such as clotrimazole cream, miconazole cream, econazole cream, ketoconazole cream, or biphenyl benzylazole cream, etc.

　　If the treatment effect of the aforementioned method is not satisfactory, the following drugs can be taken internally: ①Ketoconazole, 400mg per day for 5 days; ②Fluconazole 150mg, taken as a single dose orally; ③Itraconazole 200mg, twice a day (one-day therapy) or 200mg once a day, taken continuously for 3 days.

　　(2) Recurrent Vulvovaginal Candidiasis (RVVC)

　　Commonly seen in clinical practice, although certain triggers can be found, the factors causing the prevalence and objective existence of the disease are not clear. At present, there is no optimal treatment plan. However, prevention or maintenance of systemic antifungal therapy can effectively reduce the recurrence rate of RVVC. Cultures should be performed to confirm all RVVC cases before starting maintenance treatment.

　　① Itraconazole, oral, 200mg on the first day of the menstrual cycle, for a total of 6 menstrual cycles, then 200mg per day, 3-day course.

　　② Ketoconazole, oral, 100mg per day, for a total of 6 months.

　　(3) Candidal balanitis

　　Rinse the skin lesions with normal saline or 0.1% lavender solution 2-3 times a day. After rinsing, apply 1%-2% gentian violet solution or the above imidazole ointment externally. Those with long foreskins should undergo circumcision after recovery to prevent recurrence. Those with concurrent urethritis can take ketoconazole, fluconazole, or trichonazole orally.

　　2. External Treatment Method

　　(1) Rinse the vagina and vulva with 2% baking soda solution once a day, for 10 times as one course. Generally, after rinsing the vagina, medication should be inserted into the vagina.

　　(2) Insert nystatin powder, tablets, suppositories, and ointments into the vagina or apply them to the perineum, 100,000 to 200,000 units each time, once a day, for 10-14 days as one course.

　　(3) Clotrimazole suppositories, 500mg each time, inserted into the vagina, 3-4 times a day, for 2 weeks in a row.

　　(4) Apply 1% gentian violet solution to the vagina and vulva, 3-4 times a week, for 2 weeks in a row.

　　(5) 20g of Cnidium monnieri and Sophora flavescens, decoct the decoction for external washing, twice a day, for 10 days as one course.

　　(6) Boil 100g of Alpinia oxyphylla in water to 100mL, apply the medicine liquid with a cotton swab to clean the vagina, once a day, for 7-10 days as one course.

　　(7) Mix a little glycerin with Bingpao powder, rinse the vagina, and apply the powder with a cotton swab inside the vagina, once in the morning and once in the evening.

　　(8) Alpinia oxyphylla, indigo, and saltpeter in equal proportions, finely ground, mixed with glycerin, applied to the vulva and vagina with a cotton swab, once in the morning and once in the evening.