Diagnostic value of some common symptoms of vulvovaginal candidiasis

Nội dung text: Diagnostic value of some common symptoms of vulvovaginal candidiasis

1. Journal of military pharmaco-medicine 7-2013 DIAGNOSTIC VALUE OF SOME COMMON SYMPTOMS OF VULVOVAGINAL CANDIDIASIS Le Tran Anh*; Trinh Thi Thu Huong** Summary Vulvovaginitis is a common disease in women, mainly caused by bacteria, fungi or trichomonas.... Accurate diagnosis of the cause of disease helps treat effectively. Objective: to study the value of some common symptoms/group of symptoms in diagnosing the cause of Candida in vaginitis. Methods: collect and analyze of clinical data and results of direct examination of vaginal discharge from 196 patients examined at Obstetrics Clinic, 103 Hospital from May to July 2013. Results: the common symptoms/signs in women with vaginal candidiasis were vaginal discharge (89.8%), pruritus (78.6%), swelling (89%). The appearance of vaginal discharge was highly sensitive for fungal vaginitis (89.8%) but low specificity (14.3%). Discharge characteristics were of little value in diagnosing vulvovaginal candidiasis (VVC). Swelling, itching signs had high sensitivity (88.8% and 78.6%) but low specificity while perineal dermatitis and worse before menstruation had relatively high specificity (83.7% and 76.5%) but low sensitivity. The combination of symptoms raised the specificity but reduced the sensitivity. The combination with highest specificity was vaginal pain and perineal dermatitis (92.9%), pain worse before menstruationd (90.3%), itching and perineal dermatitis (90.0%). Conclusion: Accuracy diagnosis of predicting VVC has been demonstrated to be low if based only on clinical findings without laboratory confirmation. * Key words: Vaginitis, Candida; Sensitivity; Specificity; Positive predictive value; Negative predictive value. Introduction metabolic tests to determine the species but clinical manifestations may be suggestive. Vulvovaginitis constitutes one of the most A thorough grasp of the sensitivity, specificity, common problems in clinical medicine. Bacterial etc of common symptoms in vulvovaginitis vaginosis, candidiasis and trichomoniasis are is of great value in clinical practice. We responsible for 90% of cases of infectious conducted this study to: Examine the diagnostic origin. Candida species caused 20 to 25% value of some common symptoms of of the cases of infectious vulvovaginitis, vulvovaginitis caused by Candida species. ranked second only after the bacteria. An estimated 75% of women will have at least subjects and methods one episode of VVC and 40 - 45% will have The prospective study was conducted two or more episodes [2]. The diagnosis of from May to July 2013 at 103 Hospital. A VVC is confirmed by laboratory diagnosis, total of 196 women were recruited and which involves microscopic examinations, interviewed in-clinic. Each subject underwent isolation of the yeast in culture medium and general physical and pelvic examination. * Vietnam Military Medical University **103 Hospital Address correspondence to Le Tran Anh: Vietnam Military Medical University E.mail: dieplinhanh@yahoo.com
2. Journal of military pharmaco-medicine 7-2013 A vaginal swab from the posterior fornix the case group with VVC (n = 98), and the was obtained at the time of speculum control group with vulvovaginitis but no examination. Vaginal discharge was collected blastoconidia structures or pseudohyphae for direct microscopy and/ or Gram staining. was observed (n = 98). Data processing and The diagnosis of VVC was made in women statistical analysis were performed using who had signs and symptoms of vaginitis and SPSS 13.0 and Excels 2003. The sensitivity wet preparation or Gram stain of vaginal (Se), specificity (Sp), positive predictive discharge demonstrated yeasts and/or value (PPV) and negative predictive value pseudohyphae [2]. Two groups were selected: (NPV) were expressed as percentage. Results and Discussion Table 1: Prevalence of symptoms and signs in case group (n = 98). Symptoms and signs n % Symptoms Discharge 88 89.8 Pruritus 77 78.6 Worse before menstruation 44 44.9 Soreness 32 32.7 Dyspareunia 30 30.6 Pelvic pain 5 5.1 Dysuria 5 5.1 Burning 4 4.1 Signs Swelling 87 89.0 Perineal dermatitis 25 25.5 Excoriation 17 17.5 Vaginal discharge and itching were the were itching, discharge, erythema and edema, most common symptoms (89.8% and 78.6% which may intensify in the premenstrual respectively) and symptoms got worse before period [4]. A study by Karaer A et al (2005) menstruation. The most common sign was showed that itching was more common in swelling (89%), followed by perineal dermatitis patients with yeast infections than in and excoriation. patients without defined diagnosis [3]. An exacerbation before menstruation was quite VVC is clinically characterized by itching, common because of the acidity as well as burning, urination pain and a thick, white, glycogen level increases [4], which favours odourless granulated vaginal discharge, the growth of Candida. As oestrogen levels increase, vulva and vagina are frequently oedemic so does glycogen containing superficial cells and hyperemic [4]. The most common symptoms in the vagina. It is characteristic for these
3. Journal of military pharmaco-medicine 7-2013 symptoms to flare-up in the premenstrual All those symptoms and signs may be week and improve with the onset of manifested in vaginitis caused by other menstruation [10]. agents so which are suggestive of VVC? Table 2: Sensitivity, specificity, PPV and NPV of discharge in diagnosing VVC. Characteristics of discharge Case Control Se Sp PPV NPV Appearance Yes 88 84 89.8 14.3 51.2 58.3 No 10 14 Malodour Yes 51 37 58.0 56.0 58.0 56.0 No 37 47 White colour Yes 60 57 68.2 32.1 51.3 49.1 No 28 27 Yellow colour Yes 28 27 28.5 59.1 29.0 58.0 No 60 57 Granulated form Yes 33 39 33.6 46.2 33.8 45.8 No 55 45 Froth form Yes 26 26 26.4 60.2 27.0 58.9 No 62 58 Mucus form Yes 29 19 29.5 68.4 30.5 66.1 No 59 65 The sensitivity of discharge for detecting characteristics [9]. The findings showed infection with candidiasis was high (89.8%) that discharge did not help distinguish but the specificity was low (14.3%). The between VVC, bacterial vaginitis and no discharge had different forms, colours and defined diagnosis [3] and discharge in these odours but characteristics were neither patients were often odourless [3, 4, 9]. Other sensitive nor specific for VVC. The predictive study showed that a thick, curly discharge was of strongly diagnostic value of VVC values of features of discharge for predicting (Sp 97%) but this form was less frequent VVC were low. (Se 16%) [1]. In our study, no curly discharge This is consistent with other studies. was noted. Previous findings also demonstrated According to Trien N (2006), vaginal that the minority of women (9.5%) with vaginal discharge in women with VVC has no specific discharge had VVC [3].
4. Journal of military pharmaco-medicine 7-2013 Table 3: Sensitivity, specificity, PPV and NPV of common symptoms (other than discharge) in diagnosing VVC. Symptom/sign Case Control Se Sp PPV NPV Pruritus Yes 77 75 78.6 23.5 50.7 52.3 No 21 23 Swelling Yes 87 76 88.8 22.4 53.4 66.7 No 11 22 Pain Yes 32 31 32.7 68.4 50.8 50.4 No 66 67 Worse before menstruation Yes 44 23 44.9 76.5 65.7 58.1 No 54 75 Perineal dermatitis Yes 25 16 25.5 83.7 61.0 52.9 No 73 82 The symptoms with a high sensitivity findings of other investigators. A study by were swelling and pruritus (88.8 and 78.6%) Anderson et al (2004) showed that the but its specificity was low. The predictive sensitivity and specificity of swelling in values implied that the clinical diagnosis diagnosing VVC were 91% and 23% respectively was not suited for diagnosis of VVC. [1]. According to Trien N (2006), swelling of vulvar and vaginal was common sign in Similar findings were noted by other vaginitis caused by yeasts or trichomonas authors. VVC is generally considered to but rare in vaginitis caused by bacteria [9]. feature inflammatory symptoms (irritation Another study showed that women with VVC and itching) predominantly [3] and swelling had more frequent swelling than women as well as pruritus are criteria to diagnose without VVC [5]. VVC [2] Pruritus was described in VVC Perineal dermatitis symptoms had low but not in vaginitis caused by bacteria or sensitivity (25.5%) but relatively high specificity trichomonas [9]. A study by Ngoc TTM, Tai (83.7%). The result of study by MT Rodrigues ND (2010) showed that women with VVC et al. (2009) showed that the injuries may had more pronounced itching than women extend to the perineal, perianal and inguinal without VVC [5]. regions [4]. PPV got worse before menstruation High sensitivity (88.8%) but low specificity at the rate of 65.7%, which needs much (22.4%) of swelling sign was similar to the more attention in the practice clinical diagnosis.
5. Journal of military pharmaco-medicine 7-2013 Table 4: Sensitivity, specificity, PPV and NPV of some common combined symptoms in diagnosing VVC. Combination of symptoms/signs Case Control Se Sp PPV NPV Discharge and pruritus Yes 70 64 71.4 34.7 52.2 54.8 No 28 34 Discharge and pain Yes 28 25 28.6 74.5 52.8 51.0 No 70 73 Discharge and swelling Yes 72 61 73.5 37.8 54.1 58.7 No 26 37 Discharge and perineal dermatitis Yes 24 16 24.5 83.7 60.0 52.6 No 74 82 Discharge worse before menstruation Yes 33 23 33.6 63.7 34.4 62.1 No 55 61 Pruritus and pain Yes 28 28 28.6 71.4 50.0 50.0 No 70 70 Pruritus and swelling Yes 54 46 55.1 53.1 54.0 54.2 No 44 52 Pruritus and perineal dermatitis Yes 21 14 21.3 90.0 22.5 85.1 No 77 84 Pruritus worse before menstruation Yes 28 20 36.4 73.3 58.3 52.9 No 49 55 Pain and swelling Yes 70 64 71.4 34.7 52.2 54.8 No 28 34 Pain and perineal dermatitis Yes 6 7 6.1 92.9 46.2 49.7 No 92 91 Pain worse before menstruation Yes 4 3 12.5 90.3 57.1 50.0 No 28 28 Swelling and perineal dermati tis Yes 24 14 24.5 85.7 63.2 53.2 No 74 84
6. Journal of military pharmaco-medicine 7-2013 The combination of symptoms/signs had lower sensitivity but higher specificity than symptoms or signs alone in diagnosing VVC. Combinations with highest specificity were pain and perineal dermatitis (92.9%), pain worse before menstruation (90.3%), pruritus and perineal dermatitis (90.0%), swelling and perineal dermatitis (85.7%). These data are compatible with those in other publications. Prevalence of VVC when two in three clinical signs observed (pruritus, discharge, and erythema) was 16.7% and increased by 40.1% when all the three signs were observed [7]. Karaer A et al (2005) found that combinations of the vaginal signs and symptoms were increasingly rare, though the probability of correct diagnosis of VVC increased when both signs and both symptoms were present. The prevalence of VVC when discharge present was 9.5%; pruritus was 15.5%; this figure reached 28% when combinations between discharge and pruritus or odour discharge and pruritus presented [3]. The results showed that no symptoms/ signs or groups of symptoms/signs were specific for vaginal candidosis. These findings are consistent with those of the literature, accuracy in predicting candidiasis has been demonstrated to be low if based only on clinical findings, without laboratory confirmation [1, 4]. Diagnosis should rely on microscopic examination of a sample from the lateral vaginal wall, a rapid, simple and convenient technique demonstrating yeasts and/or pseudohyphae. Vaginal culture is not routinely necessary in women with recurrent symptoms or with typical symptoms and a negative direct examination [6]. Treatment based on symptoms alone is common clinical practice but results in the overtreatment of a large number of women. Syndromic diagnosis of reproductive tract infections leads to substantially unnecessary treatment in Vietnam [8]. Conclusions By analyzing data of 196 women suffering from vaginitis, we draw some conclusions: - The common symptoms in women with vaginal candidiasis were vaginal discharge (89.8%), pruritus (78.6%), the most common sign was swelling (89%). Less common symptoms/signs were pain, burning sensation, vaginal or abdominal pain, urinary disorders, perineal dermatitis, excoriation. The symptoms are usually worse before menstruation. - The appearance of vaginal discharge was highly sensitive for fungal vaginitis (89.8%) but low specificity (14.3%). Discharge characteristics were of little value in diagnosing VVC. - Swelling, itching had high sensitivity (88.8% and 78.6%) but low specificity in diagnosing VVC while perineal dermatitis getting worse before menstruation had relatively high specificity (83.7% and 76.5%) but low sensitivity. Predictive values of these symptoms were moderate (52.3 - 66.7%). - The combination of symptoms raised the specificity but reduced the sensitivity. The combination with the highest specificity were sore and perineal dermatitis (92.9%), pain worse before menstruation and (90.3%), itching and perineal dermatitis (90.0%). To summarize, accuracy has been demonstrated in predicting VVC to be low based only on clinical findings, without laboratory confirmation. References 1. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004, Mar 17; 291 (11), pp.1368-1379. 2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. Morbidity and Mortality Weekly Report. 2006, August 4, Vol 55, No. RR-11. 3. Karaer A, Boylu M, Avsar AF. Vaginitis in Turkish women: symptoms, epidemiologic - microbiologic
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