This is a condition caused by a yeast infection and affects both men and women. It is usually ‘candida albicans’ and is often called ‘thrush’. This fungus is always present on our bodies, on the skin and in various locations like the mouth / genital area, and is a normal comensal within the vagina. In other words, it has every right to be there! Why it should overgrow on occasions and cause thrush is a bit of a mystery, but there are a few well defined predisposing factors. The commonest is a course of antibiotics, particularly broad spectrum antibiotics, like Tetracyclines. These kill off the other normal bacteria and allow the thrush to dominate. There is no doubt that hormonal changes can sometimes predispose to this and, for example, many women who become pregnant do seem to have candida throughout the pregnancy. There is, however, absolutely no definitive study showing that the oral contraceptive pill has any influence in either clearing up or generating thrush. Many studies have looked at this and the general advice now is that there is no point in fooling around with changing contraceptive pills in an effort to stop chronic candida. If someone is on a pill that they are generally happy with “best stick with it”. A third factor ,which can be important , is the friction of intercourse. Of all, this is the easiest to deal with and any woman who is prone to candidiasis should use extra lubrication whether she thinks she needs it or not. The one we recommend here, is “Sensilube”, this can be bought in many chemist shops and is even available at Sainsbury’s. A silicone based lubricant as in the Millenium range also coats the vulval area and adds an element of skin protection that some patients like.
Moving on to the more medical treatments, there is a whole plethora of pessaries and creams available, as well as the oral treatments like Diflucan and Sporanox. Here in G.U.Medicine, we tend to use single use pessaries as the first line of treatment, as we feel more confident about applying a local treatment to what we consider a local problem. Therefore , a Canesten pessary and cream is often our first line, and we recommend to the patients, that should they recognise thrush developing, they can simply purchase this themselves over the counter and self-treat. For people who develop chronic recurrences and find that the Canesten helps, we usually give them several pessaries and tell them to use a pessary every fortnight or every month for about 3-6 months, and then stop and see what happens. It is also important for them to have one or two spare pessaries at home, so that they know they have the treatment to hand, should they feel symptoms developing. The same applies to the oral treatments. If people find them of benefit, there is nothing wrong with taking a treatment every month or fortnight to give someone a complete break from the problem, and then stop and see what happens.
Obviously, it is important to be reasonably certain that one is dealing with thrush. In the GU setting, we do a full screen and can be quite confident about this. In general practice, I think using one’s sixth sense and knowledge of the patient, one can usually treat someone presenting with an itchy discharge with good symptoms as thrush, and only if things don’t go according to plan there might be a consideration that it could be something else. For example, very rarely, it could be trichomonas or even chlamydia. Obviously, every woman with thrush and every case of thrush does not need investigations.
There is not a single scrap of evidence to suggest that treating the male partner is of any benefit to the woman. Most male partners of women with candidiasis don’t get any symptoms and can be left alone. Few men do occasionally get recurrent candida and for them it is appropriate to treat if they get a rash or the typical spots of candida on the glans or prepuce with Canesten cream. It is Not considered a sexually transmitted infection. We all have our own candida on board and a few extra from someone else is not a cause of the infection. As previously indicated, the friction of intercourse can seem to make people think that it is sexually transmitted because they often develop the symptoms within two days of sex. Some men do, in fact, get symptoms within minutes of intercourse if their partner has candidiasis, and this is more likely to be a “chemical dermatitis”. This is not unusual, as yeast produce all kinds of volatile chemicals (we are familiar with the alcohol production!) and it is not surprising that this could cause a rash and irritation on the glans penis and foreskin in some men. Simple washing is usually enough for this, but again, canesten cream can help. We therefore only recommend Canesten cream to the male partner if there is actually a male partner problem. There is no point in screening these often bewildered men, or giving them oral therapies, etc.
Finally, some home treatments are worth a mention. Many women find that live natural yogurt is soothing and can actually help restore the normal vaginal flora. Another patient I had recently absolutely swears by the stuff she bought in a herbal shop called “Tea Tree Oil”. Obviously, our philosophy is that if somebody finds something that works for them- that’s terrific and they should stick with it.
Also, it must be understood that this is a distressing nuisance condition. It greatly interferes with someone’s sex life and can cause great difficulty within a relationship. The patients must understand that it is a problem that can disappear as mysteriously as it first started for no apparent reason. Many people go through bad patches of chronic candidiasis and they find it just stops happening. They must have the means to treat it at home, so that they can get treatment under way immediately. They must also understand that this is their condition and can be easily managed within their own home. It can be managed to a degree that should not interfere with sex and relationships.