Vulvovaginal candidiasis: Diagnostic and therapeutic approaches used by Dutch general practitioners

Abstract

Objective: To establish how general practitioners (GPs) in the Netherlands diagnose and treat vaginal candidiasis. Methods: Questionnaires were sent to 1160 Dutch GPs. The GPs were asked to make an inventory of the annual number of consultations for vulvovaginal candidiasis. Furthermore, information was requested with regard to diagnostic examinations performed and preferred treatment when dealing with vulvovaginal candidiasis. Results: 380 (32.87%) GPs returned the questionnaire, of which 189 GPs worked in single-person practices (n=189). The group of 380 GPs consisted of 269 (70.8%) males and 111 (29.2%) females. On average, GPs reported 105.6 consultations concerning vaginal candidiasis per practice per year. Only 61 (16.1%) Dutch GPs always or often performed microscopy when diagnosing candidiasis, while 143 (37.6%) GPs never used a microscope to confirm their diagnosis. Furthermore, only 30 (7.9%) GPs regularly took Candida cultures, whereas 154 GPs (40.5%) never took a vaginal swab to diagnose acute candidiasis. Treatment of choice was mostly miconazole (50%) or clotrimazole (24%).

Conclusion: GPs often diagnose “vulvovaginal candidiasis” in their practices, but often do not perform the laboratory examinations required to confirm their putative diagnosis. This may lead to wrong diagnoses and maltreatment with antimycotics, without cure of the patients’ vaginal complaints.

• Vaginal
• candidiasis
• GP
• Dutch
• microscopy
• culture

Introduction

Vaginal complaints account for large numbers of visits to general practices in the Netherlands. Approximately 50 per 1000 female patients per year visit their general practitioner (GP) with complaints of vaginal discharge, abnormal in amount, colour, and/or smell [1]. In 25 to 35%, candidiasis is the underlying cause of the vulvovaginal discomfort [1], [2]. Other possible causes of abnormal vaginal discharge include bacterial vaginosis (BV, 20%), infections by Trichomonas vaginalis (5–10%), Chlamydia trachomatis (5–10%), or Neisseria gonorrhoeae (1%), and non-infectious causes such as chemicals or irritants [1–4]. About 30% of women with vaginal complaints remain without a diagnosis [1], [2]. Current recommendations for Dutch GPs to correctly diagnose vaginitis involve speculum examination and microscopy, since the predictive value of assessing vaginal complaints alone is low [1], [5], [6]. Presence of Candida infection is confirmed when pseudohyphae are observed during microscopic examination (wet mount): discharge mixed with a drop of 10% potassium hydroxide (KOH) [1–8]. BV is diagnosed when the pH of the usually thin and homogeneous discharge is ≥4.5, the “whiff test” is positive, and clue cells can be seen during wet-mount examination [1–6], [9]. Since sensitivity of microscopy for yeasts is at best 50 to 60% [7], and the “whiff test” is also positively associated with trichomoniasis [2], GPs can also take a vaginal swab to culture the putative pathogen causing the complaints [5]. Nevertheless, speculum examination can be uncomfortable for the patient and wet-mount examination is laborious. Therefore, we hypothesized that vulvovaginal candidiasis is often not correctly diagnosed by GPs and thus remains untreated. The present study was undertaken to evaluate how GPs in the Netherlands diagnose and treat Candida vaginitis.

Methods

In September 2005, questionnaires were sent to 1160 general practices in the Netherlands. Standardized forms were used to record characteristics such as the age and gender of the physician, and the name of the village or town where their practice was situated. Since family doctors in the Netherlands are recommended to use the International Classification of Primary Care (ICPC) coding system [10], the general practitioners were asked to present the number of consultations given annually within ICPC category X72 (vulvovaginal candidiasis). In addition, GPs were asked to report the percentage of patients that had suffered from recurrent vulvovaginal candidiasis (RVVC), defined as four or more episodes of candidiasis within 1 year. Furthermore, information was requested with regard to the methods used by GPs to diagnose acute and recurrent Candida infection (vaginal examination, microscopy, culture, etc.) as well as the preferred medical treatment.

Results

Of the total of 1160 GPs who were addressed, 380 (32.8%) filled out and returned the questionnaire.

Information about the general practices

The group of 380 GPs consisted of 269 (70.8%) males and 111 (29.2%) females. The average age of the male physicians was 50.4 years, and the average age of the female GPs 44.0 years. Of the total of 380 GPs, 189 GPs worked in a single-person practice.

Incidence

The GPs reported on average 105.6 cases (ranging from 7 to 225 cases) of vaginal candidiasis per general practice per year. A number of GPs (n=112) did not answer this question, mainly because their database was not (yet) computerized. In addition, the GPs reported that, on average, one in five (19.1%) women with candidiasis suffered from RVVC.

Diagnosis

In Table I, the methods used by the 380 physicians to diagnose acute and recurrent vulvovaginal candidiasis are shown. This table reveals that a substantial part of the general practitioners never performed microscopy or took a Candida culture when “diagnosing” vaginal candidiasis. However, binomial testing shows that GPs obtained Candida cultures more often when RVVC was suspected. Chi-square tests performed showed no significant differences between the gender of the GP and the use of methods such as taking a history of the patient or examining the patient's vulva or vagina to diagnose acute or recurrent VVC. However, significant differences between male and female GPs were found when methods such as performing microscopy or taking a culture to diagnose acute and recurrent VVC were concerned (microscopy in acute VVC: chi-square test = 9.29, df 3, p<0.05; and in RVVC: chi-square test = 6.65, df 3, p<0.1; culture in acute VVC: chi-square test = 9.31, df 3, p<0.05; and in RVVC: chi-square test = 11.74, df 3, p<0.01). Male GPs were more likely to use the microscope to diagnose acute or recurrent VVC, while female GPs were more likely to take a culture when encountering acute or recurrent VVC.

Table I.  The methods used by the 380 physicians to diagnose acute (VVC) and recurrent (RVVC) vulvovaginal candidiasis.

	Episodes of vulvovaginal candidiasis
	Evaluation of vaginal complaints		Examination vulva		Examination vagina (speculum)		Microscopy		Culture
	VVC	RVVC	VVC	RVVC	VVC	RVVC	VVC	RVVC	VVC	RVVC
Always	350	350	93	154	61	140	14	41	2	42
Often	23	22	179	115	174	120	47	71	28	90
Sometimes	2	5	103	104	142	108	172	136	192	130
Never	2	0	1	4	1	11	143	126	154	111
Not answered	3	3	4	3	2	1	4	6	4	7
Total	380	380	380	380	380	380	380	380	380	380

Treatment

Most physicians (n=310, 81.6%) preferred local (vaginal) treatment of acute vaginal candidiasis, while 37 GPs (9.7%) started systemic treatment and 30 GPs (7.9%) prescribed a combination of vaginal and oral treatment. Almost all the respondents prescribed medication for 1 to 3 days to treat acute VVC. There was a lot of variation in the medication prescribed but, when converted into generic names, it became clear that most GPs prescribed miconazole (50%) or clotrimazole (24%) when an acute Candida vaginitis was suspected. Other choices of treatment comprised fluconazole (14%), butoconazole (7%), and itraconazole/other (1%; 14 GPs [4%] did not answer this question). A chi-square test performed showed no significant differences between gender of the GP and prescribed medication (chi-square test = 0.837, df 4, p>0.1). In the case of recurrent VVC, the preferred treatment was so divergent (from simple changes in medication, to combinations of different kinds of medication and prolongation of therapy), that it was impossible to create a clear picture. Three hundred GPs confirmed that they used a form of prophylactic antimycotic treatment when confronted with RVVC.

Discussion

We examined how GPs in the Netherlands diagnose and treat Candida vaginitis, by sending questionnaires to 1160 Dutch general practitioners. Although Dutch GPs encounter large numbers of patients complaining of vaginal discomfort annually, they scarcely perform vaginal examination, microscopy, and culture sampling. Women are frequently diagnosed with vulvovaginal candidiasis and treated with antimycotics solely based on symptoms and inspection only. This finding conflicts with the advice given by the Dutch General Practitioners Guideline, which recommends performing office-based tests when confronted with women with vaginal complaints [1]. Mårdh et al. [5] and Schaaf et al. [6] confirmed that the predictive value of vaginal complaints such as itching, burning, and white, curdy discharge is low. Therefore, taking a vaginal specimen to culture pathogens is considered by some authors mandatory in order to be able to rule out other causes of vaginitis, especially when dealing with patients with recurrent vaginal complaints [11], [12]. Other studies have shown that, without the benefit of microscopy or culture, as many as half of the women routinely diagnosed with vulvovaginal candidiasis may suffer from other conditions [7], [13–15]. Not employing microscopy or culture could therefore lead to an overestimated prevalence and incidence of “vulvovaginal candidiasis”, thereby encouraging the widespread abuse of antimycotics [16–18]. Unfortunately, the GPs in our study did not indicate why certain clinical or microbiological evaluations were not performed. We can only assume that microscopy was not carried out due to lack of experience or because of time constraints. However, efforts are clearly needed to improve the quality of the clinical diagnosis of vaginal complaints.

In our study, the preferred therapy of vulvovaginal candidiasis differed strongly. Most of the GPs prescribe topical clotrimazole or miconazole for 1 to 3 days when Candida vaginitis is suspected. Some physicians choose another form of local treatment, and only a few prescribe oral medication. This finding is in concordance with the Dutch General Practitioners Guideline, which recommends treating Candida vaginitis with clotrimazole or miconazole (vaginal) tablets once only. In case of recurrent vulvovaginal candidiasis, the duration of treatment can be prolonged [1], [19].

As is always the case with questionnaire-based investigations, results may be hampered by response bias. However, we presume that most of our current respondents overestimated their use of speculum examination, microscopy, and culture sampling. This assumption strengthens our conclusion that office-based testing to confirm vulvovaginal candidiasis should be stimulated.

In this study, we noted that Dutch GPs diagnose (recurrent) vulvovaginal candidiasis on the basis of gut feelings rather than adequate diagnostic procedures. Although the current clinical guidelines advocate correct procedures, much is to be gained by more frequent implementation of these guidelines by the average Dutch GP.