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.
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.)