Sandbox:Balanitis: Difference between revisions

Revision as of 18:56, 16 January 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S [2]

Synonyms and keywords: balanoposthitis

Overview

Historical Perspective

Classification

Pathophysiology

Infectious

Non-infectious

Causes

Causes of Balanitis include the following:

Candidal balanitis
Anaerobic balanitis
Aerobic balanitis
Lichen sclerosus
Lichen planus
Zoon’s (plasma cell) balanitis
Psoriasis and circinate balanitis
Eczema (including irritant, allergic and seborrhoeic)
Non-specific balanoposthitis
Fixed drug eruptions

Premalignant conditions:

Erythroplasia of Queyrat
Bowen’s disease
Bowenoid papulosis

Miscellaneous

Stevens-Johnson syndrome

Differentiating Candida Vulvovaginitis from other Diseases

Candida Vulvovaginitis must be differentiated from the following diseases which have a similar presentation:^[1]^[2]^[3]^[4]^[5]


Disease	Findings
Trichomoniasis	Presents with purulent, malodorous, thin discharge associated with burning, pruritus, and dysuria, with the signs of vaginal inflammation and elevated vaginal pH (>4.5) Motile trichomonads on wet mount are demonstrated Positive culture (Gold standard) Positive nucleic acid amplification test (NAAT)
Atrophic vaginitis	Progressive symptoms Presents with yellow and malodorous vaginal discharge, vaginal dryness, postcoital bleeding, and dyspareunia with the signs of vaginal inflammation and elevated vaginal pH (>5) Diagnosis is critical and laboratory tests help to confirm hypoestrogenic state
Desquamative inflammatory vaginitis	Chronic clinical syndrome with unknown etiology Presents with dyspareunia, dyspareunia, yellow, grey, or green profuse vaginal discharge with the signs of vaginal inflammation and elevated vaginal pH (>4.5) Microscopy shows large number of parabasal (immature squamous epithelial cells) and inflammatory cells
Bacterial Vaginosis	Presents with dysuria, vaginal discharge Fishy odor (positive whiff test) Normal vaginal PH (<4.5) On speculum examination signs of vaginal inflammation are demonstrated.

Epidemiology and Demographics

Epidemiological studies on Candida vulvovaginitis are hard to perform, because of several factors:^[6]^[7]
- Candida vulvovaginitis is not a reportable disease.
- The diagnosis of Candida vulvovaginitis is based on clinical presentation and positive laboratory findings. Relying on a positive culture alone would likely overestimate the prevalence of Candida vulvovaginitis.
- The use of over-the-counter (OTC) topical anti-fungals makes it difficult to conduct epidemiological studies.
Candida is the second most common cause of vaginal infection in young women following Bacterial Vaginosis.^[8]

Age

Incidence of Candida vulvovaginitis is higher in pregnant women.^[9]^[10]
Women in reproductive age group are prone for Candida vulvovaginits and at least one episode is reported in 70 to 75% in this population group.^[11]
40 to 50% of patients with a prior yeast infection have multiple episodes of yeast infection.^[9]
Among the adult population 5 to 8% women have more than four episodes of infection.^[12]
In 20% asymptomatic healthy adolescent women, candida species can be isolated from the vagina.^[13]

Race

Candida vulvovaginitis is more prevalent among African American women than white American women.^[12]

Risk Factors

Risk factors for Balanitis include:

Uncircumcised penis
Antibiotic use
Corticosteroid use
Immunocompromised
Diabetes
Not usually considered sexually transmitted

Screening

There are no screening procedures for Balanitis.

Natural History, Complications and Prognosis

Natural History

Prognosis

Complications

Diagnosis

History and Symptoms

Symptoms include:

Redness of foreskin or penis
Other rashes on the head of the penis
Foul-smelling discharge
Painful penis and foreskin

Physical Examination

Laboratory Findings

Treatment

Medical Therapy

Surgical Therapy

Prevention

Primary Prevention

Secondary Prevention

References

↑ Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016
↑ Bachmann GA, Nevadunsky NS (2000). "Diagnosis and treatment of atrophic vaginitis". Am Fam Physician. 61 (10): 3090–6. PMID 10839558.
↑ Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB; et al. (1988). "Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens". JAMA. 259 (8): 1223–7. PMID 2448502.
↑ Sobel JD, Reichman O, Misra D, Yoo W (2011). "Prognosis and treatment of desquamative inflammatory vaginitis". Obstet Gynecol. 117 (4): 850–5. doi:10.1097/AOG.0b013e3182117c9e. PMID 21422855.
↑ Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.
↑ Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR (1998). "Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations". Am. J. Obstet. Gynecol. 178 (2): 203–11. PMID 9500475.
↑ Sobel JD (2007). "Vulvovaginal candidosis". Lancet. 369 (9577): 1961–71. doi:10.1016/S0140-6736(07)60917-9. PMID 17560449.
↑ Allsworth JE, Peipert JF (2007). "Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data". Obstet Gynecol. 109 (1): 114–20. doi:10.1097/01.AOG.0000247627.84791.91. PMID 17197596.
↑ ^9.0 ^9.1 Hurley R, De Louvois J (1979). "Candida vaginitis". Postgrad Med J. 55 (647): 645–7. PMC 2425644. PMID 523355.
↑ García Heredia M, García SD, Copolillo EF, Cora Eliseth M, Barata AD, Vay CA; et al. (2006). "[Prevalence of vaginal candidiasis in pregnant women. Identification of yeasts and susceptibility to antifungal agents]". Rev Argent Microbiol. 38 (1): 9–12. PMID 16784126.
↑ Zuckerman, Andrea; Romano, Mary (2016). "Clinical Recommendation: Vulvovaginitis". Journal of Pediatric and AdolescentGynecology. 29 (6): 673–679. doi:10.1016/j.jpag.2016.08.002. ISSN 1083-3188.
↑ ^12.0 ^12.1 Foxman B, Marsh JV, Gillespie B, Sobel JD (1998). "Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey". J Womens Health. 7 (9): 1167–74. PMID 9861594.
↑ Barousse, M M (2004). "Vaginal yeast colonisation, prevalence of vaginitis, and associated local immunity in adolescents". Sexually Transmitted Infections. 80 (1): 48–53. doi:10.1136/sti.2002.003855. ISSN 1368-4973.

[CDC-BV-1] Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016

[pmid10839558-2] Bachmann GA, Nevadunsky NS (2000). "Diagnosis and treatment of atrophic vaginitis". Am Fam Physician. 61 (10): 3090–6. PMID 10839558.

[pmid2448502-3] Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB; et al. (1988). "Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens". JAMA. 259 (8): 1223–7. PMID 2448502.

[pmid21422855-4] Sobel JD, Reichman O, Misra D, Yoo W (2011). "Prognosis and treatment of desquamative inflammatory vaginitis". Obstet Gynecol. 117 (4): 850–5. doi:10.1097/AOG.0b013e3182117c9e. PMID 21422855.

[pmid97946645-5] Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK (1998). "Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm". Obstet Gynecol. 92 (5): 757–65. PMID 9794664.

[pmid9500475-6] Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR (1998). "Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations". Am. J. Obstet. Gynecol. 178 (2): 203–11. PMID 9500475.

[pmid17560449-7] Sobel JD (2007). "Vulvovaginal candidosis". Lancet. 369 (9577): 1961–71. doi:10.1016/S0140-6736(07)60917-9. PMID 17560449.

[pmid17197596-8] Allsworth JE, Peipert JF (2007). "Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data". Obstet Gynecol. 109 (1): 114–20. doi:10.1097/01.AOG.0000247627.84791.91. PMID 17197596.

[pmid523355-9] 9.0 ^9.1 Hurley R, De Louvois J (1979). "Candida vaginitis". Postgrad Med J. 55 (647): 645–7. PMC 2425644. PMID 523355.

[pmid16784126-10] García Heredia M, García SD, Copolillo EF, Cora Eliseth M, Barata AD, Vay CA; et al. (2006). "[Prevalence of vaginal candidiasis in pregnant women. Identification of yeasts and susceptibility to antifungal agents]". Rev Argent Microbiol. 38 (1): 9–12. PMID 16784126.

[ZuckermanRomano2016-11] Zuckerman, Andrea; Romano, Mary (2016). "Clinical Recommendation: Vulvovaginitis". Journal of Pediatric and AdolescentGynecology. 29 (6): 673–679. doi:10.1016/j.jpag.2016.08.002. ISSN 1083-3188.

[pmid9861594-12] 12.0 ^12.1 Foxman B, Marsh JV, Gillespie B, Sobel JD (1998). "Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey". J Womens Health. 7 (9): 1167–74. PMID 9861594.

[Barousse2004-13] Barousse, M M (2004). "Vaginal yeast colonisation, prevalence of vaginitis, and associated local immunity in adolescents". Sexually Transmitted Infections. 80 (1): 48–53. doi:10.1136/sti.2002.003855. ISSN 1368-4973.

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@@ Line 1: / Line 1: @@
 __NOTOC__
-{{CMG}}; {{AE}}{{AKI}}
+{{CMG}}; {{AE}}{{VD}}
-{{SK}} Vulvovaginal candidiasis, Candidal Vulvovaginitis, Fungal Vaginitis, Yeast infection, Vulvovaginal Candidosis, candida vaginitis, Genital candidiasis
+{{SK}} balanoposthitis
 ==Overview==
-Candida vulvovagintis is an infection of the [[vagina]] and the vestibulum, common in women in the reproductive age group. It is caused by various [[Candida]] species with [[Candida albicans]] most common pathogen followed by other species like [[C.glabarta]], C.krusei etc. Patients present with vulvar [[pruritus]], burning micturition and [[vaginal discharge]].The diagnosis of candidal infection requires a collaboration of clinical and diagnostic findings. Patients have typical white cottage chesee like discharge with [[hyphae]] and spores demonstrated on microscopy. Patients with uncomplicated infection respond well to topical and oral [[azole]] therapy. 5 to 8% of women develop recurrent vaginitis, which is defined as more than 4 episodes in a year. These patients require a longer duration of therapy with an induction and maintenance phase.
 ==Historical Perspective==
-*In 1839, B. Lagenbeck from Germany described a yeast-like fungus for the first time in the human oral infection "thrush." and its ability to cause it.<ref name="pmid18509848">{{cite journal |vauthors=Barnett JA |title=A history of research on yeasts 12: medical yeasts part 1, Candida albicans |journal=Yeast |volume=25 |issue=6 |pages=385–417 |year=2008 |pmid=18509848 |doi=10.1002/yea.1595 |url=}}</ref>
-*In 1923 the Candida albicans was described by Christine Marie Berkhout.  Over the years the classification of the genera and species has evolved. Obsolete names for this genus include ''Mycotorula'' and ''Torulopsis''. The species has also been known in the past as ''Monilia albicans'' and ''Oidium albicans''. The current classification is ''nomen conservandum'', which means the name is authorized for use by the [http://www.bgbm.org/iapt/nomenclature/code/SaintLouis/0000St.Luistitle.htm International Botanical Congress (IBC)].
-*The full current taxonomic classification is available at ''[[Candida albicans]]''.
-*The genus ''Candida'' includes about 150 different species. However, only a few of those are known to cause human infections. ''C. albicans'' is the most significant pathogenic (=disease-causing) species. Other ''Candida'' species causing diseases in humans include ''C. tropicalis'', ''C. glabrata'', ''C. krusei'', ''C. parapsilosis'', ''C. dubliniensis'', and ''C. lusitaniae''.
 ==Classification==
-[[Candida]] [[vulvovaginitis]] can be classified based on the duration, as well as the strain of [[Candida]] causing the infection.
+==Pathophysiology==
-===Duration===
-[[Candida]] [[vulvovaginitis]] can be divided based on the duration and number of episodes of the infection into:<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid7995997">{{cite journal |vauthors=Vazquez JA, Sobel JD, Demitriou R, Vaishampayan J, Lynch M, Zervos MJ |title=Karyotyping of Candida albicans isolates obtained longitudinally in women with recurrent vulvovaginal candidiasis |journal=J. Infect. Dis. |volume=170 |issue=6 |pages=1566–9 |year=1994 |pmid=7995997 |doi= |url=}}</ref>
+=== Infectious ===
-*'''Acute, uncomplicated''': these are usually sporadic cases of [[Candida]] [[vulvovaginitis]], which respond to topical anti-fungal therapy and have a high cure rate.
-*'''Acute, complicated''': symptoms are more severe than uncomplicated infections and typically require a combination of oral and topical [[anti-fungal]] treatment.
+=== Non-infectious ===
-*'''Recurrent Vulvovaginal Candidiasis (RVVC)''': defined as 4 or more episodes of [[Candida]] [[vulvovaginitis]] per year, usually caused by the same strain of [[Candida]]. Treatment also requires a combination of oral and topical anti-fungal agents.
-*According to 2015, Treatment of STD guidelines - Candida vulovaginitis can be classified into uncomplicated and complicated based on the following features:<ref name="pmid26602614">{{cite journal| author=Workowski KA| title=Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. | journal=Clin Infect Dis | year= 2015 | volume= 61 Suppl 8 | issue=  | pages= S759-62 | pmid=26602614 | doi=10.1093/cid/civ771 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26602614  }}</ref>
+==Causes==
+Causes of Balanitis include the following:
-{| class="wikitable"
+# Candidal balanitis
-!Uncomplicated Candida Vulvovaginitis
+# Anaerobic balanitis
-!Complicated Candida Vulvovaginitis
+# Aerobic balanitis
-|-
+# Lichen sclerosus
-|
+# Lichen planus
-*Sporadic or infrequent VVC
+# Zoon’s (plasma cell) balanitis
-*Mild-to-moderate VVC
+# Psoriasis and circinate balanitis
-*Likely to be  Candida albicans
+# Eczema (including irritant, allergic and seborrhoeic)
-*Nonimmunocompromised women
+# Non-specific balanoposthitis
-|
+# Fixed drug eruptions
-*Recurrent VVC
+Premalignant conditions:
-*Severe VVC
+# Erythroplasia of Queyrat
-*Nonalbicans candidiasis
+# Bowen’s disease
-*Women  with  diabetes,  immunocompromised conditions (e.g.,  HIV  infection),
+# Bowenoid papulosis
-debilitation,  or  immunosuppressive therapy (e.g., corticosteroids
+Miscellaneous
-|}
+Stevens-Johnson syndrome
-==Pathophysiology==
-===Vaginal Defensive mechanisms aganist Candida===
-====Innate Mechanisms====
 {| class="wikitable"
-!Defense
+!
-!Mechanism of protection
+!
-!Evidence of protection
+!
+!
 |-
-|Vaginal epithelial cells
 |
-*In Vitro inhibition of Candida growth<ref name="pmid16239581">{{cite journal| author=Barousse MM, Espinosa T, Dunlap K, Fidel PL| title=Vaginal epithelial cell anti-Candida albicans activity is associated with protection against symptomatic vaginal candidiasis. | journal=Infect Immun | year= 2005 | volume= 73 | issue= 11 | pages= 7765-7 | pmid=16239581 | doi=10.1128/IAI.73.11.7765-7767.2005 | pmc=1273905 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16239581  }}</ref>
 |
-*Protective role in vivo unknown
-*Patients with recurrent candida infections have a decreased anti Candida activity
-|-
-|Mannose-binding lectin
 |
-*Epithelial-cell associated protein which binds to candida surface mannan.<ref name="pmid18715406" />
-*Inhibits Candida growth by activating complement<ref name="pmid15243942">{{cite journal| author=Ip WK, Lau YL| title=Role of mannose-binding lectin in the innate defense against Candida albicans: enhancement of complement activation, but lack of opsonic function, in phagocytosis by human dendritic cells. | journal=J Infect Dis | year= 2004 | volume= 190 | issue= 3 | pages= 632-40 | pmid=15243942 | doi=10.1086/422397 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15243942  }}</ref>
-*Activity is genetically determined
 |
-*Decreased expression can increase the susceptibility for vaginal colonization of candida and leading to vaginitis.
 |-
-|Activated lactoferrin<ref name="pmid15603095">{{cite journal| author=Naidu AS, Chen J, Martinez C, Tulpinski J, Pal BK, Fowler RS| title=Activated lactoferrin's ability to inhibit Candida growth and block yeast adhesion to the vaginal epithelial monolayer. | journal=J Reprod Med | year= 2004 | volume= 49 | issue= 11 | pages= 859-66 | pmid=15603095 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15603095  }}</ref>
 |
-*Fungistatic and fungicidal activity
 |
-*Role in protection aganist infection is not clear
-|-
-|Vaginal bacterial flora
 |
-*Lactobacillus species compete for nutrients.
-*Bacteriocins and hydrogen peroxide inhibits yeast growth/germination
 |
-*Role in protection aganist vaginitis still unclear
 |-
-|Phagocytic systems/polymononuclear leucocytes, mononuclear cells, complement
 |
-*Mainly found in lamina propria in experimental vaginitis, help in reducing the yeast load and its invasion by phagocytosis and intracellular killing<ref name="pmid340470">{{cite journal| author=Diamond RD, Krzesicki R, Jao W| title=Damage to pseudohyphal forms of Candida albicans by neutrophils in the absence of serum in vitro. | journal=J Clin Invest | year= 1978 | volume= 61 | issue= 2 | pages= 349-59 | pmid=340470 | doi=10.1172/JCI108945 | pmc=372545 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=340470  }}</ref>
-*Nitric oxide has anti-candida activity
 |
-*Role in protection still unclear
-|}
-====Adaptive Mechanisms====
-{| class="wikitable"
-!Defense
-!Mechanism
-!Role in Protection
-|-
-|Immunoglobulin mediated immunity
-|Systemic IgM, IgG and local IgA antibodies are produced in response to the  infection<ref name="pmid4556009">{{cite journal| author=Waldman RH, Cruz JM, Rowe DS| title=Immunoglobulin levels and antibody to Candida albicans in human cervicovaginal secretions. | journal=Clin Exp Immunol | year= 1972 | volume= 10 | issue= 3 | pages= 427-34 | pmid=4556009 | doi= | pmc=1713147 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4556009  }}</ref>
-|
-*Protective role not proven.
-*Elevated titres of vaginal anti-candida IgG, IgA are detected in women with recurrent vaginitis
-*Persistent symptoms could be attributed to Anti-candida IgE<ref name="pmid8809464">{{cite journal| author=Fidel PL, Sobel JD| title=Immunopathogenesis of recurrent vulvovaginal candidiasis. | journal=Clin Microbiol Rev | year= 1996 | volume= 9 | issue= 3 | pages= 335-48 | pmid=8809464 | doi= | pmc=172897 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8809464  }}</ref>
-|-
-|Cell Mediated Immunity
 |
-Interleukin 4 (Th2) inhibits anti-candida activity of nitric oxide and protective pro-inflammatory Th1 cytokines.<ref name="pmid15735412">{{cite journal| author=Fidel PL| title=Immunity in vaginal candidiasis. | journal=Curr Opin Infect Dis | year= 2005 | volume= 18 | issue= 2 | pages= 107-11 | pmid=15735412 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15735412  }}</ref>
 |
-*Role in protection from vulvovaginitis is still not clear
-*It is still a hypothesis<ref name="pmid15102806">{{cite journal| author=Fidel PL, Barousse M, Espinosa T, Ficarra M, Sturtevant J, Martin DH et al.| title=An intravaginal live Candida challenge in humans leads to new hypotheses for the immunopathogenesis of vulvovaginal candidiasis. | journal=Infect Immun | year= 2004 | volume= 72 | issue= 5 | pages= 2939-46 | pmid=15102806 | doi= | pmc=387876 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15102806  }}</ref>
-*Patients with recurrent infection have undetectable Th2 cytokines.
 |}
-===Candida Virulence Factors===
+*
-*C.albicans exists as blastospores, germ tubes, pseudomycelia, true mycelia and  chlamydospores on special culture media. C. glabrata exists exclusively in blastospores.
-*All strains of Candida species possess a yeast surface mannoprotein which helps in adhering to epithelial cells of the [[vagina]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref>
-*[[Germination]] of the spores helps in colonizing the vagina.<ref name="pmid6327527">{{cite journal| author=Sobel JD, Muller G, Buckley HR| title=Critical role of germ tube formation in the pathogenesis of candidal vaginitis. | journal=Infect Immun | year= 1984 | volume= 44 | issue= 3 | pages= 576-80 | pmid=6327527 | doi= | pmc=263631 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6327527  }} </ref>
-*Proteolytic enzymes, toxins and phospholipase destroy the proteins that normally impair fungal invasion, enhancing the ability of [[Candida]] to colonize the [[vagina]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref><ref name="pmid2688924">{{cite journal |vauthors=Sobel JD |title=Pathogenesis of Candida vulvovaginitis |journal=Curr Top Med Mycol |volume=3 |issue= |pages=86–108 |year=1989 |pmid=2688924 |doi= |url=}}</ref><ref name="pmid12761103">{{cite journal| author=Schaller M, Bein M, Korting HC, Baur S, Hamm G, Monod M et al.| title=The secreted aspartyl proteinases Sap1 and Sap2 cause tissue damage in an in vitro model of vaginal candidiasis based on reconstituted human vaginal epithelium. | journal=Infect Immun | year= 2003 | volume= 71 | issue= 6 | pages= 3227-34 | pmid=12761103 | doi= | pmc=155757 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12761103  }}</ref>
-*Phenotypic switching of Candida is described in patients with recurrent vaginitis.<ref name="pmid3284370">{{cite journal| author=Soll DR| title=High-frequency switching in Candida albicans and its relations to vaginal candidiasis. | journal=Am J Obstet Gynecol | year= 1988 | volume= 158 | issue= 4 | pages= 997-1001 | pmid=3284370 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3284370  }}</ref>
-*C.albicans can form bio-films on the intra uterine devices or sponges causing disease recurrence.<ref name="pmid25935553">{{cite journal| author=Muzny CA, Schwebke JR| title=Biofilms: An Underappreciated Mechanism of Treatment Failure and Recurrence in Vaginal Infections. | journal=Clin Infect Dis | year= 2015 | volume= 61 | issue= 4 | pages= 601-6 | pmid=25935553 | doi=10.1093/cid/civ353 | pmc=4607736 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25935553  }}</ref>
-===Pathogenesis===
-*[[Candida (genus)|Candida]] vulvovaginitis is a microbial disease and not all patients with detectable pathogen are symptomatic. Multiple risk factors and the imbalance in the protective vaginal defenses predispose patients to develop active disease.
-*[[Candida]] vaginal infections are more common in the reproductive age group because of the high concentration of estrogen as it increases the amount of glycogen in the vagina providing a carbon source for candida organisms to colonize. It also increases the adherence of candida to the vaginal epithelial cells.<ref name="pmid11592551">{{cite journal| author=Dennerstein GJ, Ellis DH| title=Oestrogen, glycogen and vaginal candidiasis. | journal=Aust N Z J Obstet Gynaecol | year= 2001 | volume= 41 | issue= 3 | pages= 326-8 | pmid=11592551 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11592551  }}</ref>
-*The most common source of the infection is from the peri-anal area. Other less common source is sexual transmission and persistence of organisms in the vagina after treatment which is responsible for recurrence.<ref name="pmid333134">{{cite journal| author=Miles MR, Olsen L, Rogers A| title=Recurrent vaginal candidiasis. Importance of an intestinal reservoir. | journal=JAMA | year= 1977 | volume= 238 | issue= 17 | pages= 1836-7 | pmid=333134 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=333134  }}</ref>
-*The initial step of infection is colonization and symptoms appear with the invasion of the blastospores or pseudohyphae of the vaginal wall.<ref name="pmid9880475">{{cite journal| author=Fidel PL, Vazquez JA, Sobel JD| title=Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 1 | pages= 80-96 | pmid=9880475 | doi= | pmc=88907 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9880475  }}</ref>
-*The understanding of the transition from asymptomatic vaginal colonization with [[Candida]] to symptomatic [[vulvovaginitis]] is not clear.<ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref><ref name="pmid2688924">{{cite journal |vauthors=Sobel JD |title=Pathogenesis of Candida vulvovaginitis |journal=Curr Top Med Mycol |volume=3 |issue= |pages=86–108 |year=1989 |pmid=2688924 |doi= |url=}}</ref>
-===Genetics===
-*Few genetic factors are thought to be involved in patients with recurrent [[Candida]] [[vulvovaginitis]].<ref name="pmid12964847">{{cite journal| author=Calderon L, Williams R, Martinez M, Clemons KV, Stevens DA| title=Genetic susceptibility to vaginal candidiasis. | journal=Med Mycol | year= 2003 | volume= 41 | issue= 2 | pages= 143-7 | pmid=12964847 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12964847  }}</ref>
-*Supporting evidence is that candida vaginitis is common in African-American women, runs in families and its association in patients with ABO-Lewis non-secretor phenotype, a rare blood group.
-*In addition, women with recurrent [[Candida]] [[vulvovaginitis]] were found to have decreased concentrations of [[mannose binding lectin]] (MBL), hence, the variant (MBL) gene is thought to be a contributing factor in the development of [[Candida]] [[vulvovaginitis]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid16256117">{{cite journal |vauthors=Liu F, Liao Q, Liu Z |title=Mannose-binding lectin and vulvovaginal candidiasis |journal=Int J Gynaecol Obstet |volume=92 |issue=1 |pages=43–7 |year=2006 |pmid=16256117 |doi=10.1016/j.ijgo.2005.08.024 |url=}}</ref><ref name="pmid18715406">{{cite journal |vauthors=Donders GG, Babula O, Bellen G, Linhares IM, Witkin SS |title=Mannose-binding lectin gene polymorphism and resistance to therapy in women with recurrent vulvovaginal candidiasis |journal=BJOG |volume=115 |issue=10 |pages=1225–31 |year=2008 |pmid=18715406 |doi=10.1111/j.1471-0528.2008.01830.x |url=}}</ref>
-===Gross Pathology===
-On speculum examination typical curdy white discharge is present.
-<gallery>
-[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
-Image:speculum_vagina.jpg|left|thumb|350px|This photograph is a speculum examination of the vagina with Candida infection and the typical thick, curdy vaginal discharge.
-</gallery>
-===Microscopic Pathology===
-Microscopic examination of the wet mount with 10% KOH or saline demonstrates hyphae, pseudohyphae and blastospores.<gallery>
-Image:Calbicans.jpg|left|thumb|350px|This is a a microscopic image of Candida albicans, grown on cornmeal agar medium.
-<br clear="left"/>
-Image:Renal candidiasis 005.jpeg|left|thumb|350px|This higher-power photomicrograph shows the yeasts and pseudohyphae of Candida organisms.
-<br clear="left"/>
-Image:Renal candidiasis 006.jpeg|left|thumb|350px|This high-power photomicrograph shows the yeasts (1) and pseudohyphae (2).
-<br clear="left"/>
-</gallery>
-===Associated Conditions===
-*[[Candida]] [[vulvovaginitis]] may be associated with other pathogens that cause [[vulvovaginitis]] including ''[[Trichomonas vaginalis]]'' and ''[[Gardnerella vaginalis]]''. The presence of these diseases in combination is common therefore it is important to rule out other etiologies before initiation of anti fungal treatment.<ref name="pmid23354954">{{cite journal |vauthors=Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE |title=Mixed vaginitis-more than coinfection and with therapeutic implications |journal=Curr Infect Dis Rep |volume=15 |issue=2 |pages=104–8 |year=2013 |pmid=23354954 |doi=10.1007/s11908-013-0325-5 |url=}}</ref><ref name="pmid15026404">{{cite journal |vauthors=Anderson MR, Klink K, Cohrssen A |title=Evaluation of vaginal complaints |journal=JAMA |volume=291 |issue=11 |pages=1368–79 |year=2004 |pmid=15026404 |doi=10.1001/jama.291.11.1368 |url=}}</ref>
-==Causes==
-Candida vulvovaginitis is caused by many different species of Candida. They are divided into [[Candida albicans]] and Candida non-albicans species based on the causative pathogen:
-===Common Causes===
-*Candida albicans: These strains are isolated in 85 to 95% patients with yeast infection.<ref name="pmid12932875">{{cite journal| author=Corsello S, Spinillo A, Osnengo G, Penna C, Guaschino S, Beltrame A et al.| title=An epidemiological survey of vulvovaginal candidiasis in Italy. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2003 | volume= 110 | issue= 1 | pages= 66-72 | pmid=12932875 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12932875  }} </ref>
-*Candida non albicans: Candida glabrata is the most common isolated pathogen in this group affecting 10 to 20% of women and is associated with recurrent Candida vulvovaginitis.<ref name="pmid15456373">{{cite journal| author=Okungbowa FI, Isikhuemhen OS, Dede AP| title=The distribution frequency of Candida species in the genitourinary tract among symptomatic individuals in Nigerian cities. | journal=Rev Iberoam Micol | year= 2003 | volume= 20 | issue= 2 | pages= 60-3 | pmid=15456373 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15456373  }} </ref>
-===Less Common Causes===
-These are less commonly isolated in patients but is important to identify the species as they are less sensitive to standard azole therapy and cause recurrent infection.<ref name="pmid12237629">{{cite journal| author=Bauters TG, Dhont MA, Temmerman MI, Nelis HJ| title=Prevalence of vulvovaginal candidiasis and susceptibility to fluconazole in women. | journal=Am J Obstet Gynecol | year= 2002 | volume= 187 | issue= 3 | pages= 569-74 | pmid=12237629 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12237629  }} </ref><ref name="pmid12794215">{{cite journal| author=Holland J, Young ML, Lee O, C-A Chen S| title=Vulvovaginal carriage of yeasts other than Candida albicans. | journal=Sex Transm Infect | year= 2003 | volume= 79 | issue= 3 | pages= 249-50 | pmid=12794215 | doi= | pmc=1744683 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12794215  }} </ref>
-*Candida parapsilosis<ref name="pmid16040326">{{cite journal| author=Nyirjesy P, Alexander AB, Weitz MV| title=Vaginal Candida parapsilosis: pathogen or bystander? | journal=Infect Dis Obstet Gynecol | year= 2005 | volume= 13 | issue= 1 | pages= 37-41 | pmid=16040326 | doi=10.1080/10647440400025603 | pmc=1784559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16040326  }} </ref>
-*Candida tropicalis
-*Candida krusei<ref name="pmid12384840">{{cite journal| author=Singh S, Sobel JD, Bhargava P, Boikov D, Vazquez JA| title=Vaginitis due to Candida krusei: epidemiology, clinical aspects, and therapy. | journal=Clin Infect Dis | year= 2002 | volume= 35 | issue= 9 | pages= 1066-70 | pmid=12384840 | doi=10.1086/343826 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12384840  }} </ref>
 ==Differentiating Candida Vulvovaginitis from other Diseases==
 Candida Vulvovaginitis must be differentiated from the following diseases which have a similar presentation:<ref name=CDC-BV> Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016 </ref><ref name="pmid10839558">{{cite journal| author=Bachmann GA, Nevadunsky NS| title=Diagnosis and treatment of atrophic vaginitis. | journal=Am Fam Physician | year= 2000 | volume= 61 | issue= 10 | pages= 3090-6 | pmid=10839558 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10839558  }} </ref><ref name="pmid2448502">{{cite journal| author=Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB et al.| title=Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens. | journal=JAMA | year= 1988 | volume= 259 | issue= 8 | pages= 1223-7 | pmid=2448502 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2448502  }} </ref><ref name="pmid21422855">{{cite journal| author=Sobel JD, Reichman O, Misra D, Yoo W| title=Prognosis and treatment of desquamative inflammatory vaginitis. | journal=Obstet Gynecol | year= 2011 | volume= 117 | issue= 4 | pages= 850-5 | pmid=21422855 | doi=10.1097/AOG.0b013e3182117c9e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422855  }} </ref><ref name="pmid97946645">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref>
@@ Line 197: / Line 107: @@
 Candida vulvovaginitis is more prevalent among African American women than white American women.<ref name="pmid9861594">{{cite journal| author=Foxman B, Marsh JV, Gillespie B, Sobel JD| title=Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey. | journal=J Womens Health | year= 1998 | volume= 7 | issue= 9 | pages= 1167-74 | pmid=9861594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9861594  }} </ref>
 ==Risk Factors==
-The following risk factors have been implicated in predisposing patients to [[Candida]] [[vulvovaginitis]]:
+Risk factors for Balanitis include:
-*Previous infection with [[Candida]] [[vulvovaginitis]]<ref name="pmid2305918">{{cite journal |vauthors=Foxman B |title=The epidemiology of vulvovaginal candidiasis: risk factors |journal=Am J Public Health |volume=80 |issue=3 |pages=329–31 |year=1990 |pmid=2305918 |pmc=1404680 |doi= |url=}}</ref>
+* Uncircumcised penis
-*Previous infection with ''[[Neisseria gonorrheae|Neisseria gonorrhea]]''<ref name="pmid97946644">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref>
+* Antibiotic use
-*Nulliparity<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
+* Corticosteroid use
-*Luteal phase of the menstrual cycle <ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
+* Immunocompromised
-*Recent [[antibiotic]] use<ref name="pmid12825971">{{cite journal| author=Wilton L, Kollarova M, Heeley E, Shakir S| title=Relative risk of vaginal candidiasis after use of antibiotics compared with antidepressants in women: postmarketing surveillance data in England. | journal=Drug Saf | year= 2003 | volume= 26 | issue= 8 | pages= 589-97 | pmid=12825971 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12825971  }} </ref>
+* Diabetes
-*[[Pregnancy]]<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
+* Not usually considered sexually transmitted
-*[[Diabetes Mellitus]]<ref name="pmid11835694">{{cite journal |vauthors=de Leon EM, Jacober SJ, Sobel JD, Foxman B |title=Prevalence and risk factors for vaginal Candida colonization in women with type 1 and type 2 diabetes |journal=BMC Infect. Dis. |volume=2 |issue= |pages=1 |year=2002 |pmid=11835694 |pmc=65518 |doi= |url=}}</ref><ref name="pmid12433331">{{cite journal |vauthors=Donders GG |title=Lower Genital Tract Infections in Diabetic Women |journal=Curr Infect Dis Rep |volume=4 |issue=6 |pages=536–539 |year=2002 |pmid=12433331 |doi= |url=}}</ref>
-*[[Obesity]]
-*[[Immunosuppression]], such as [[HIV]] or [[glucocorticoid]] use<ref name="pmid12636961">{{cite journal |vauthors=Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, Sobel JD |title=Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity |journal=Obstet Gynecol |volume=101 |issue=3 |pages=548–56 |year=2003 |pmid=12636961 |doi= |url=}}</ref>
-*Condom use<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref>
-====Risk Factors for Recurrent Candida Vulvovaginitis<ref name="pmid26164695">{{cite journal| author=Sobel JD| title=Recurrent vulvovaginal candidiasis. | journal=Am J Obstet Gynecol | year= 2016 | volume= 214 | issue= 1 | pages= 15-21 | pmid=26164695 | doi=10.1016/j.ajog.2015.06.067 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26164695  }} </ref>====
-{| class="wikitable"
-!Microbial Factors
-!Genetic Factors
-!Host Behavioural Factors
-!Other Risk Factors
-|-
-|
-*Non-albicans Candida species
-|
-*Lewis blood group non-secretor status
-*African American race
-*Familial history of recurrent Candida vulvovaginitis
-|
-*Oral contraceptive
-*Sponge/intrauterine device use
-*Intercourse frequency/ periodicity<ref name="pmid14709186">{{cite journal| author=Reed BD, Zazove P, Pierson CL, Gorenflo DW, Horrocks J| title=Candida transmission and sexual behaviors as risks for a repeat episode of Candida vulvovaginitis. | journal=J Womens Health (Larchmt) | year= 2003 | volume= 12 | issue= 10 | pages= 979-89 | pmid=14709186 | doi=10.1089/154099903322643901 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14709186  }}</ref>
-*Orogenital sexual activity
-|
-*Antibacterial use
-*Uncontrolled diabetes
-*HIV
-*Corticosteroids
-*Hormone replacement therapy
-|}
-<small>Table adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71<ref name="pmid17560449">{{cite journal| author=Sobel JD| title=Vulvovaginal candidosis. | journal=Lancet | year= 2007 | volume= 369 | issue= 9577 | pages= 1961-71 | pmid=17560449 | doi=10.1016/S0140-6736(07)60917-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560449  }} </ref></small>
 ==Screening==
-There are no screening procedures for Candida vulvovaginitis.
+There are no screening procedures for Balanitis.
 ==Natural History, Complications and Prognosis==
 ===Natural History===
-Candida vulvovaginitis is a common infection of women in reproductive age group. Patients present with vulvar pruritus, [[dysuria]], and [[vaginal discharge]]. Half of the affected patients have multiple episodes of the infection and less than 10% have recurrent infection.<ref name="pmid98804752">{{cite journal| author=Fidel PL, Vazquez JA, Sobel JD| title=Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 1 | pages= 80-96 | pmid=9880475 | doi= | pmc=88907 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9880475  }}</ref>
 ===Prognosis===
-[[Candida albicans]] vulvovaginitis has excellent prognosis with [[azole]] therapy. Patients with non Candida albicans infections are prone to have recurrence and treatment with boric acid and oral [[fluconazole]] has good prognosis.<ref name="pmid98804753">{{cite journal| author=Fidel PL, Vazquez JA, Sobel JD| title=Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 1 | pages= 80-96 | pmid=9880475 | doi= | pmc=88907 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9880475  }}</ref>
 ===Complications===
-Candida vulvovaginitis is a self limiting disease with no complications.
 ==Diagnosis==
-Diagnosis of Candida vulvovaginitis requires a correlation of clinical features, microscopic examination, and vaginal culture.
 ===History and Symptoms===
-Symptoms of [[vulvovaginitis]] caused by Candida species are indistinguishable and include the following:<ref name="pmid97946642">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref><ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref>
-*[[Pruritus]] is the most significant symptom
+Symptoms include:
-*Change in the amount and the color of [[vaginal discharge]]: It is characterized by a thick, white "cottage cheese-like" vaginal discharge
+* Redness of foreskin or penis
-*Pain on urination ([[dysuria]])
+* Other rashes on the head of the penis
-*Pain on sexual intercourse (dyspareunia)
+* Foul-smelling discharge
-*[[Vulvovaginal]] soreness
+* Painful penis and foreskin
-*Symptoms aggravate a week before the menses
+*
 ===Physical Examination===
-[[Candida]] [[vulvovaginitis]] requires a careful examination of the external genitalia, the vaginal sidewalls and the cervix. Signs include:<ref name="pmid97946643">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref><ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
+*
-*[[Edema]] and [[erythema]] of the vulva and labia
-*[[Fissures]] and excoriations of the external genitalia
-*Thick whitish vaginal discharge adherent to the vaginal walls
-*[[Cervix]] is not affected and is normal
 ===Laboratory Findings===
-The laboratory findings consistent with the diagnosis of [[Candida]] [[vulvovaginitis]] include:<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid22519657">{{cite journal |vauthors=Mendling W, Brasch J |title=Guideline vulvovaginal candidosis (2010) of the German Society for Gynecology and Obstetrics, the Working Group for Infections and Infectimmunology in Gynecology and Obstetrics, the German Society of Dermatology, the Board of German Dermatologists and the German Speaking Mycological Society |journal=Mycoses |volume=55 Suppl 3 |issue= |pages=1–13 |year=2012 |pmid=22519657 |doi=10.1111/j.1439-0507.2012.02185.x |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>
+*
-*[[Vaginal]] pH: [[vaginal]] pH is normal (ranges from 4.0-4.5)
-*Wet mount or Saline preparation: It will help in detection of [[hyphae]], clue cells and motile [[trichomonas]] differentiating different causes of vaginitis.
-*10% Potassium hydroxide preparation: It is more sensitive than wet mount to demonstrate budding blastospores or pseudohyphae.
-*Culture: Culture for diagnosing [[Candida]] [[vulvovaginitis]] not recommended in patients with positive microscopy. However, it should be done in a symptomatic woman with a negative microscopy and a normal vaginal pH.  Culture using Sabouraud agar, Nickerson’s medium, or Microstix-candida medium identify Candida species with equal sensitivity.
-===Approach to patient with Candida Vulvovaginitis===
-The following is a algorithm for diagnosis and treatment of vulvovaginal candidiasis :
-{{Family tree/start}}
-{{Family tree | | | | | | A01 | | | |A01= Symptomatic Vaginitis}}
-{{Family tree | | | | | | |!| | | | | }}
-{{Family tree | | | | | | |!| | | | | }}
-{{Family tree | | | | | | C01 | | | |C01= Whitish discharge adherent to the vaginal walls, excoriations and fissures in the genital area}}
-{{Family tree | | | | | | |!| | | | | }}
-{{Family tree | | | | | | |!| | | | | }}
-{{Family tree | | | | | | E01 | | | |E01= Perform direct microscopy of the vaginal discharge with saline or 10% KOH<br> Estimate pH of vaginal discharge}}
-{{Family tree | | | | | | |!| | | | | }}
-{{Family tree | | |,|-|-|-|^|-|-|.|}}
-{{Family tree | |F01| | | | |F02| |F01=Negative direct microscopy<br> pH < 4.5| F02= Positive direct microscopy}}
-{{Family tree | | |!| | | | | | |!| | | | | | }}
-{{Family tree | |G01| | | | |G02| | | |G01= Send for culture<br>Consider azole therapy|G02= No culture necessary }}
-{{Family tree | | | | | | | | | |!| | | | }}
-{{Family tree | | | | | | | |,|-|^|-|-|.| }}
-{{Family tree | | | | | | | H01| | |H02|H01=pH < 4.5<br>No excess WBC's|H02= pH > 4.5<br>Excess WBC's}}
-{{Family tree | | | | | | | |!| | | | |!| }}
-{{Family tree | | | | | | |I01| | |I02|I01=Start azole therapy|I02=Consider mixed infection}}
-{{Family tree/end}}
-<small>Algorithm adopted from Vulvovaginal candidiasis Lancet 2007; 369: 1961–71<ref name="pmid17560449">{{cite journal| author=Sobel JD| title=Vulvovaginal candidosis. | journal=Lancet | year= 2007 | volume= 369 | issue= 9577 | pages= 1961-71 | pmid=17560449 | doi=10.1016/S0140-6736(07)60917-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560449  }} </ref></small>
 ==Treatment==
 ===Medical Therapy===
-According to, 2016 Update by the Infectious Diseases Society of America medical therapy for Candida vulvovaginitis includes<ref name="PappasKauffman2015">{{cite journal|last1=Pappas|first1=Peter G.|last2=Kauffman|first2=Carol A.|last3=Andes|first3=David R.|last4=Clancy|first4=Cornelius J.|last5=Marr|first5=Kieren A.|last6=Ostrosky-Zeichner|first6=Luis|last7=Reboli|first7=Annette C.|last8=Schuster|first8=Mindy G.|last9=Vazquez|first9=Jose A.|last10=Walsh|first10=Thomas J.|last11=Zaoutis|first11=Theoklis E.|last12=Sobel|first12=Jack D.|title=Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America|journal=Clinical Infectious Diseases|year=2015|pages=civ933|issn=1058-4838|doi=10.1093/cid/civ933}}</ref>:
-*Uncomplicated candida Vulvovaginits:
-**1st line :Any topical [[Antifungals|antifungal]] agents can be used and all of them have equal efficacy
-**Alternative : Single 150mg dose of oral [[fluconazole]] is recommended
-*Severe acute Candida vulvovaginitis:
-**1st line: Oral [[fluconazole]] 150mg, given every 72 hours for a total of 2 or 3 doses
-*Candida glabrata: When unresponsive to oral [[azoles]]
-**1st line: Topical intravaginal [[boric acid]] administered in a gelatin capsule, 600mg daily for 14 days
-**2nd line: [[Nystatin]] intravaginal suppositories, 100,000 units daily for 14 days
-**3rd line: Topical 17% [[flucytosine]] cream alone or in combination with [[amphotericin B]] cream daily for 14 days
-*Recurring vulvovaginal candidiasis:
-**1st line: 10 to 14 days of induction therapy with a topical agent or oral [[fluconazole]], followed by [[fluconazole]], 150mg weekly for 6 months
-====Candida Vulvovaginitis in HIV positive women====
-*Treatment of symptomatic Candida vulvovaginitis  in [[Human Immunodeficiency Virus (HIV)|HIV]]-positive women is similar to HIV-negative individuals.
 ===Surgical Therapy===
-There are no surgical options for Candida vulvovaginitis.
 ==Prevention==
 ===Primary Prevention===
-*There are no primary preventive measures for candidal infection.
-===Secondary Prevention===
+=== Secondary Prevention ===
-*Prophylactic maintainence of fluconazole is helpful in patients with idiopathic recurrent candida vulvovaginitis and in secondary recurrent vulvovaginitis associated with [[lichen sclerosus]] or topical estrogen application.<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>
+*
+*
 ==References==
 {{Reflist|2}}