What is the best treatment for a patient with vaginal itching and urinalysis results indicating leukocytosis, hematuria, and crystalluria, despite a negative urine culture?

Treatment for Vaginal Itching with Abnormal Urinalysis Findings

The most appropriate treatment for this patient with vaginal itching and abnormal urinalysis findings is topical vaginal antifungal therapy, as this presentation is most consistent with vulvovaginal candidiasis despite the urinary findings.

Differential Diagnosis Analysis

When evaluating a patient with vaginal itching and abnormal urinalysis findings, it's important to distinguish between several possible conditions:

1. Vulvovaginal Candidiasis (VVC)

   • Vaginal itching is a hallmark symptom
   • Presence of mucus in urine sample suggests vaginal contamination
   • Negative urine culture rules out bacterial UTI

2. Urinary Tract Infection

   • Ruled out by negative urine culture
   • Leukocytes in urine could represent contamination from vaginal inflammation

3. Interstitial Cystitis/Bladder Pain Syndrome

   • Can present with hematuria in up to 41% of cases 1
   • Usually presents with bladder/pelvic pain and urinary frequency rather than vaginal itching

Diagnostic Approach

The presence of:

• Vaginal itching (primary symptom)
• Many mucous threads in urine
• Negative bacterial culture
• Leukocytes in urine (likely from vaginal contamination)

Strongly suggests vulvovaginal candidiasis with urinary sample contamination from vaginal secretions.

Treatment Algorithm

1. For Vulvovaginal Candidiasis (Primary Diagnosis):

   • First-line treatment: Topical azole therapy for 5-7 days OR oral fluconazole 150 mg single dose 2
   • For complicated VVC (severe symptoms, non-albicans species): Extended topical therapy for 7-14 days OR fluconazole 150 mg every 72 hours for 3 doses 2

2. For Symptomatic Relief of Urinary Symptoms:

   • Consider phenazopyridine 200 mg three times daily for 2 days for urinary discomfort if present 3, 4
   • Note: Phenazopyridine should not be used for more than 2 days and patients should be warned about orange discoloration of urine 3

3. For Postmenopausal Women (if applicable):

   • Consider vaginal estrogen therapy as this reduces risk of both vaginal infections and UTIs 2

Important Considerations

• Avoid antibiotics: With negative urine culture, antibiotics are not indicated and may worsen vaginal candidiasis
• Diagnostic pitfall: Leukocyte esterase positivity in urine can result from vaginal contamination and does not necessarily indicate UTI 5
• Follow-up: If symptoms persist after antifungal treatment, consider:
  • Wet mount examination to confirm diagnosis
  • Vaginal culture for non-albicans Candida species
  • Evaluation for other causes of vaginitis (bacterial vaginosis, trichomoniasis)

Prevention Strategies

For patients with recurrent vaginal infections:

• Increase fluid intake 2
• Consider probiotics containing strains that support vaginal flora 2
• For postmenopausal women, vaginal estrogen therapy is strongly recommended 2

The presence of calcium oxalate crystals and RBCs in urine without infection is likely incidental and not related to the primary complaint of vaginal itching, but should be monitored if persistent.