What is the appropriate initial evaluation and treatment for a patient presenting with vaginal pruritis and odor?

From the Guidelines

The initial evaluation for vaginal pruritus and odor should include a thorough history, physical examination, and diagnostic testing, with a focus on identifying the underlying cause, which is commonly bacterial vaginosis, vulvovaginal candidiasis, or trichomoniasis, as recommended by the 2021 Centers for Disease Control and Prevention guidelines 1. The patient's history should include questions about symptoms, medical history, and sexual history. A physical examination should be performed to assess for signs of infection, such as discharge, odor, and vaginal irritation.

• Diagnostic testing should include a vaginal pH test, microscopic examination of vaginal discharge (wet mount), and potassium hydroxide (KOH) preparation to identify the cause of symptoms.
• For bacterial vaginosis, first-line treatment is oral metronidazole 500 mg twice daily for 7 days, or metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days, as recommended by the Centers for Disease Control and Prevention 1.
• For vulvovaginal candidiasis, prescribe fluconazole 150 mg oral single dose or topical azoles like clotrimazole 1% cream for 7-14 days, as recommended by the Infectious Diseases Society of America 1.
• Trichomoniasis requires metronidazole 2 g orally in a single dose or 500 mg twice daily for 7 days, as recommended by the Centers for Disease Control and Prevention 1. Patients should avoid douching, scented products, and tight-fitting clothing during treatment.
• Sexual partners may need treatment for certain conditions like trichomoniasis, as recommended by the Centers for Disease Control and Prevention 1. The American Academy of Pediatrics recommends a speculum examination to collect samples for laboratory and office-based analysis, including wet prep, potassium hydroxide examination, and vaginal pH testing 1. The most recent and highest quality study, published in 2022, recommends the use of molecular testing for the diagnosis of vulvovaginal candidiasis, which has high clinical accuracy and can help guide treatment decisions 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Evaluation of Vaginal Pruritis and Odor

• The patient's history of present illness (HPI) should include the duration of symptoms, characteristics of the discharge, and any associated symptoms such as dysuria, frequency, or abdominal pain 2.
• The HPI template can be amended to include more specific questions about the patient's symptoms, such as:
  • Vaginal pruritis - Complains of vaginal pruritis for the past _ days, describes the pruritis as _ (mild, moderate, severe).
  • Vaginal discharge - Describes the discharge as _ (thin, thick, malodorous), and notes any associated symptoms such as itching or burning.
  • Associated symptoms - Denies or endorses dysuria, frequency, urgency, or hematuria.
  • Medical history - Notes any recent use of antibiotics, and any over-the-counter (OTC) treatments tried.
  • Sexual history - Notes if the patient is sexually active, and if they have any new partners.
  • Last menstrual period (LMP) - Notes the date of the patient's LMP.

Differential Diagnosis

• The differential diagnosis for vaginal pruritis and odor includes:
  • Bacterial vaginosis
  • Vulvovaginal candidiasis
  • Trichomoniasis
  • Atrophic vaginitis
• Each of these conditions has distinct characteristics and diagnostic criteria, such as:
  • Bacterial vaginosis: milky discharge, pH greater than 4.5, positive whiff test, clue cells on microscopic examination 2, 3.
  • Vulvovaginal candidiasis: thick, white discharge, dysuria, vulvovaginal pruritus and swelling, microscopic examination of a sample from the lateral vaginal wall 2, 3.
  • Trichomoniasis: foul-smelling, frothy discharge, vaginal inflammatory changes, culture and DNA probe testing 2, 3.

Treatment Options

• Treatment options for vaginal pruritis and odor depend on the underlying cause, and may include:
  • Antifungal medications for vulvovaginal candidiasis, such as fluconazole 4, 5.
  • Antibiotics for bacterial vaginosis, such as metronidazole 2, 3.
  • Antiprotozoal medications for trichomoniasis, such as metronidazole 2, 3.
• Maintenance therapy with fluconazole may be effective in preventing recurrent vulvovaginal candidiasis 4, 6.