GENITAL INFECTION There are many types of genital infection is including with sexual transmitted disease.

The common of genital infection and STD are vulvovaginal candidiasis and syphilis (STD). Detail of these disease as below: INTRODUCTION VULVOVAGINAL CANDIDIASIS Vulvovaginal candidiasis (VVC) is a second common genital infection cases (70%) and also known as vaginal candidiasis, yeast infection, and genital candidiasis. The fungus most commonly that caused VVC is called Candida albicans, (>92%) and can be found on warm and moist area of the body. This disease is common in all women, but may occur more frequently and more severely in immunocompromised women. PATHOPHYSIOLOGY OF VULVOVAGINAL CANDIASIS The normal vaginal epithelium cornifies which is a thickened layer of epithelial cells and develop under the influence of estrogen and have function in protecting women against infection. A normal vaginal discharge consists of 1-4 mL of fluid that is white or transparent, thick, and odorless. This physiologic discharge is formed by sloughing epithelial cells, normal bacteria, and vaginal transudate. The discharge may be noticeable during pregnancy, oral contraceptive pill use, or at mid menstrual cycle, close to the time of ovulation. The normal pH of vaginal secretions is 4.0 until 4.5. This pH is maintained by lactobacillus (produces hydrogen peroxide and lactic acid), diphtheroids, and Staphylococcus epidermidis. Lactobacillus is found in 62-88% of women. Vaginal pH may increase with age, phase of menstrual cycle, sexual activity, contraception choice, pregnancy, presence of necrotic tissue or foreign bodies, and use of hygienic products or antibiotics (Mark J Leber, 2009; Anuritha Tirumani, 2009) TYPES OF VULVOVAGINAL CANDIDIASIS There are two types of VVC which including uncomplicated VVC and complicated VVC. Uncomplicated VVC is sporadic or infrequent VVC. It is mild or moderate VVC, albican candidiasis and normally it is given infection to nonimmunocompromised women. Other types of VVC are complete VVC or also known as recurrent or chronic VVC (RVVC). This kind of VVC

is severe VVC and categorized to nonalbicans candidiasis. RVVC usually defined as four or more episodes of symptomatic VVC in 1 year, affects a small percentage of women (<5%). The pathogenesis of RVVC is poorly understood, and the majority of women with RVVC have no apparent predisposing or underlying conditions. Vaginal cultures should be obtained from patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including nonalbicans species, particularly Candida glabrata. Usually, women with uncontrolled diabetes, debilitation, or are immunosuppression, or those who are pregnant tend to get this kind of infection. (Armen Hareyan, 2004) ASSESSMENT OF VULVAVAGINAL CANDIDIASIS Normally, when patient came with VVC, they will be ask about past history of sexual intercous, characteristic of vaginal discharge, source of infection, past history of gynecologic problem or other symptoms (Silvia Abularach, Jean Anderson, 2005) Besides that patient will be ask about medical history such: Type and duration of symptoms Previous vaginal yeast infection Oral contraceptive use Recent or ongoing broad-spectrum antibiotic therapy Recent corticosteroid therapy Sexual exposures (to evaluate for sexually transmitted infections) While, in physical examination, we will inspect type and color of discharge, level of pain, the present of tenderness or mass. We also need check of vital signs because VVC always associate with fever. (Clin Evid. 2004) Diabetes history Cushing syndrome Obesity Hypothyroidism Pregnancy Use of douches, vaginal deodorants, or bath additives

CLINICAL MENIFESTATION OF VULVOVAGINAL CANDIDIASIS Symptoms of VVC can be identified by doing physical examination on patient. Symptoms of superficial site of mucosa which is at vaginal mucosa, we can found white or yellow discharge, with pruritus and local excoriation. We also can see white or gray raised patches on vaginal walls, with local inflammation and dyspareunia. If there is involved with systemic infection, it will produces chills with high spiking fever, hypotension, prostration, myalgias, arthralgias, and a rash. Besides that patient will feel intensely itching of the genitals part with painful or burning urination, and painful intercourse. CAUSES/ETIOLOGY OF VULVOVAGINAL CANDIDIASIS There are many types of causes that can lead to VVC. The cause of infection during premenarchal period is because of poor perineal hygiene, chemical irritants such as bubble baths and lotions. Other than that, it may causes by present of vaginal foreign bodies or by infection of pinworm, GABHS and also by skin conditions such as Eczema, psoriasis, and seborrhea. Besides that, etiologies also usually associated with women of childbearing age. These etiologies including sexual contact especially with multiple sexual contacts, no method of birth control, history of STD, infections by bacterial or fungal such as G vaginalis (bacterial vaginosis), Candida species, and Trichomonas species and chemical irritants. In addition, recent broadspectrum antibiotics such as tetracycline, ampicillin, and cephalosporins and pregnancy also can cause VVC. Atrophic vaginitis is most common cause of vulvovaginitis in postmenarchal women.( Dr Amanda Oakley, 1997) TREATMENT OF VULVOVAGINAL CANDIDIASIS Medical treatment Normally patient with VVC treat by given medication which is including antifungal vaginal medications (creams, tablets and suppositories). The optimal treatment for recurrent vulvovaginal candidiasis has not yet been defined (Dr Amanda Oakley, 1997). But there are some drug used to treat RVVC such as:

Topical Azoles Butoconazole 2% cream 5 g PV for 3 days*

100-mg tablets administered intravaginally for seven days Butoconazole 2% cream 5 g (sustained release) One full applicator (5 g) administered PV application x 1 intravaginally for three days Clotrimazole 1% cream 5 g PV for 714 days* 150 mg administered orally (one dose) Clotrimazole 100 mg vaginal tablet for 7 days 200 mg administered orally once daily for 14 days Clotrimazole 100 mg vaginal tablet, 2 tablets 400 mg administered orally once daily for 14 days for 3 days Clotrimazole 500 mg vaginal tablet x 1 600-mg vaginal suppository administered twice daily for 14 days

Miconazole 2% cream 5 g PV for 7 days* Miconazole 200 mg vaginal suppository for 3 Two 100-mg tablets administered intravaginally days* twice weekly for six months Miconazole 100 mg vaginal suppository for 7 Two 200-mg tablets administered orally for five days* days after the menses for six months Tioconazole 6.5% ointment 5 g PV x 1* One half of a 200-mg tablet administered orally once daily for six months Terconazole 0.4% cream 5 g PV for 7 days One full applicator (5 g) administered vaginally once a week Terconazole 0.8% cream 5 g PV for 3 days 150 mg administered orally once a month Terconazole 80 mg vaginal suppository for 3 One 200-mg tablet administered orally once a days month * Available over the counter. Two 200-mg tablets administered orally once a PV, vaginally. month Note: These creams are oil-based and may weaken latex condoms and diaphragms. Oral agent Fluconazole 150 mg po x 1 (source:CDC 2002) Other treatment 1. Vinegar douches. Douching may remove healthy bacteria that line the vagina but this not encourage by doctor because douching may worsen the condition. 2. Eating yogurt that contains live acidophilus cultures (or eating acidophilus capsules): 3. Used antihistamines or topical anesthetics: (Am Fam Physician, 2000) 600-mg vaginal suppository administered once daily during menstruation (5-day menses)

INVESTIGATION OF VULVOVAGINAL CANDIDIASIS Normally, investigation that doing for VCC patients are physical and pelvic examination, test of womens urine and samples of vaginal discharges. Before the exam, sexual intercourse and douching should be avoided for one to two days to avoid complicating the diagnosis. During the pelvic examination, inspection on the woman's vaginal canal and cervix for discharge, sores, and any local pain or tenderness will be done. Speculum will be inserted into the vagina to examine the cervix. This may be uncomfortable because of pressure on the vaginal tissues. Besides that, the culture swabs of any vaginal discharge to determine if the infection is fungal (yeast), protozoan (trichomoniasis), or bacterial (bacterial vaginosis) by viewing discharge sample under a microscope to look for organisms that cause vaginal yeast infections. In some cases, a Pap test will be doing to rule out the possibility of cervical dysplasia or cancer. The test is then sent to a laboratory, and results typically take one week. Patient may undergo a colposcopy or biopsy if the woman's cervix appears abnormal. Colposcopy involves a lighted microscope to examine the surface of the cervix. A biopsy involves taking a tissue sample for testing. The doctor also may use a blood test to assess for antibodies associated with Candida albicans. This test is normally used only to determine a widespread (systemic) infection has developed. (Brian Acacio, 2010) OBJECTIVE OF VULVOVAGINAL CANDIDIASIS CARE To reduce complication that can be come out from VVC problem To help patient with VVC making self-care when they at home To provide information about vulvuvaginal candidiasis, so that they can understand about the diseases To reduce risk for infection to not infected VVC patient by teaching them proper selfcare. To reduce pain or suffer that patient facing.

REFERENCES: Belinda Sheary, Linda Dayan. Recurrent vulvovaginal candidiasis. Australian Family Physician, March 2005; Vol. 34, No. 3 Guide to the Clinical Care of Women with HIV/AIDS, Silvia Abularach, Jean Anderson. 2005 edition. Available online at http://hab.hrsa.gov/publications/womencare05/WG05chap6.htm#WG05chap6e

Sobel J, Faro S, Force RW, et al. Vulvovaginal candidiasis: Epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol 1998;178:20311. Treatment of recurrent vulvovaginal candidiasis Am Fam Physician. 2000 Jun 1;61(11):3306-12, 3317. Available at online http://www.ncbi.nlm.nih.gov/pubmed/10865926 February 1, 2010. Vaginal Infections, Brian Acacio, MD. March 14, 2008 Available at online http://www.emedicinehealth.com/vaginal_infections/page5_em.htm#Exams%20and%20Tests Vulvovaginal Candidiasis. Armen Hareyan, http://www.emaxhealth.com/4/558.html Aug 11th, 2004. Available at online

Vulvovaginal candidiasis. Dr Amanda Oakley. DermNet NZ. Available at online http://dermnetnz.org/fungal/vaginal-candidiasis.html 17 Oct 2009. 2010