What is the cause of itching without dysuria, with a thick white discharge, and negative yeast and bacterial vaginosis (BV) swab results, requiring treatment (tx)?

From the Guidelines

For a patient with itching, thick white discharge, and negative tests for yeast and bacterial vaginosis (BV), I recommend empiric treatment with fluconazole 150mg oral single dose, as it is a highly effective treatment for vulvovaginal candidiasis (VVC) and has a high cure rate, even with negative swab results, due to the possibility of false negatives 1.

Key Considerations

• The patient's symptoms, such as itching and thick white discharge, are consistent with VVC, which is a common cause of vaginal infections, affecting 70–75% of women during their lifetime 1.
• Despite negative swab results, false negatives can occur with yeast infections, and empiric treatment with antifungals is often recommended 1.
• If symptoms persist after treatment, consider testing for sexually transmitted infections like trichomoniasis, chlamydia, and gonorrhea, as well as other possibilities such as contact dermatitis, allergic reactions, or cytolytic vaginosis.

Additional Recommendations

• For symptom relief while awaiting resolution, recommend wearing loose cotton underwear, avoiding douching and scented products, and using cool water compresses.
• If the initial treatment fails, a follow-up examination with more comprehensive testing would be appropriate, including consideration of alternative diagnoses such as trichomoniasis, which can cause similar symptoms 2.
• Yeast testing can sometimes miss infections, particularly when the fungal burden is low or with certain Candida species that aren't detected by standard tests, highlighting the importance of empiric treatment and follow-up evaluation 1.

From the Research

Symptoms and Diagnosis

• Itching without dysuria, with a thick white discharge, and negative yeast and bacterial vaginosis (BV) swab results may indicate a condition that requires further investigation 3, 4, 5, 6, 7
• The symptoms described do not align with the typical presentation of bacterial vaginosis, which is characterized by a malodorous discharge and a pH greater than 4.5 3, 4, 5, 6, 7
• The presence of a thick white discharge is more commonly associated with vulvovaginal candidiasis, although the negative yeast swab result suggests that this may not be the cause 3, 4, 5, 6, 7

Possible Causes

• Atrophic vaginitis, which is caused by estrogen deficiency, can produce symptoms of vaginal dryness, itching, irritation, discharge, and dyspareunia 5, 7
• Allergic and irritant contact forms of vaginitis can also occur, although these are less common 7
• Inflammatory vaginitis may improve with topical clindamycin as well as steroid application 5

Treatment

• Treatment of noninfectious vaginitis should be directed at the underlying cause 5
• Atrophic vaginitis is treated with hormonal and nonhormonal therapies 5, 7
• Topical estrogen is effective in treating atrophic vaginitis 4, 7