DIABETES, TRICHOMONIASIS, MONILIASIS
Vulvovaginal infections are a common occurrence and frequent cause for clinical evaluation. Although most frequently these are not associated with any underlying risk factor, women who are immunocompromised or have diabetes mellitus are at increased risk for opportunistic infections such as yeast infections.
Even without infection, vulvar itching is a common occurrence in the
diabetic woman. It may persist with or without a varying degree of dermatitis
secondary to scratching. Frequently, a mycotic vulvitis or vulvovaginitis is
superimposed and gives the characteristic picture of diabetic vulvitis. This is
manifested by an inflamed, dark-red, or beefy appearance, which first involves
the vestibule and labia minora and then spreads to adjacent parts. The high
percentage of sugar in the secretions bathing the vulva is thought to favor the
growth of various fungi. As a result of irritation, excoriations and furuncles
are common.
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| Plate 6-10 |
Moniliasis is a vaginal infection caused by ubiquitous fungi found in the
air or as common inhabitants of the vagina, rectum, and mouth. Vulvovaginitis
caused by yeast belonging to the Candida albicans group has been
variously designated as mycotic vaginitis, vulvovaginitis, yeast
vulvovaginitis, vaginal thrush, or moniliasis. On speculum examination, white,
cheesy, irregular plaques are found, partially adherent to the congested mucosa
of the vagina and cervix. These are easily wiped off, sometimes leaving a red
margin or shallow ulceration. The associated vaginal discharge may resemble
curds and whey and may have a characteristic yeasty odor. The presence of most
yeast species elicits a strong allergic response, resulting in the vestibule
and lower portions of the labia becoming edematous, inflamed, and covered by
minute vesicles, pustules, or ulcerations. Moniliasis may occur during
childhood, sexual maturity, and after the menopause. It has a definite
predilection for pregnant and diabetic women, in whom it may be particularly
resistant to treatment. The diagnosis is made by the typical clinical
appearance and the microscopic demonstration of mycelia and yeast buds in the
wet smear under high dry power. The thread-like mycelia and conidia may be more
apparent after the use of 10% potassium hydroxide solution or in stained
smears. If further confirmation is desired, a culture may be made on special
culture media. Perineal hygiene (keeping the perineal area clean and dry,
avoiding tight or synthetic undergarments), education regarding prevention, and
encouraging completion of the prescribed course of antifungal therapy are all
appropriate interventions.
A vaginal infection by the sexually transmitted single-celled anaerobic
flagellate protozoan Trichomonas vaginalis accounts for approximately
one-quarter of all vaginal infections. In the acute stage of trichomoniasis, a
vulvitis is usually also present, as evidenced by congestion of the vestibule
and the inner aspects of the labia minora. On separating the inflamed labia, a
thick, odoriferous, bubbly
discharge may be seen in the vestibule. Presenting symptoms suggestive of
trichomoniasis include a sudden increase in vaginal discharge, itching about
the vulva, a burning sensation as urine passes over the inflamed area, and
dyspareunia. A wet mount examination of secretions from the vulva or vagina
suspended in saline will demonstrate a fusiform protozoon slightly larger than
a white blood cell with three to five flagella extending from the narrow end.
These provide active movement. Culture or monoclonal antibody testing may
be obtained but is seldom necessary. Evaluation for concomitant sexually
transmissible infections should be strongly considered. Newer technologies have
been introduced, resulting in tests that have a sensitivity greater than 83%
and a specificity higher than 97% but require 10 to 45 minutes to complete. (Fa
se positives may occur in low prevalence
populations.)
