What is the recommended in-office test and treatment for yeast infections?

In-Office Diagnosis and Treatment of Vaginal Yeast Infections

The recommended in-office test for vaginal yeast infections is microscopic examination of vaginal secretions using saline wet mount and 10% potassium hydroxide (KOH) preparation, followed by culture in recurrent or complicated cases. 1

Diagnostic Testing Algorithm

Primary Diagnostic Methods

• Collect vaginal secretions and spread directly onto a microscopy slide for examination 1
• Perform pH testing of vaginal discharge - yeast infections typically have pH <4.5 1
• Prepare a saline wet mount to visualize yeast cells and pseudohyphae 1
• Perform 10% KOH preparation to dissolve cellular material and better visualize fungal elements 1
• Look for characteristic pseudohyphae and budding yeast forms under microscopy 1

Secondary Diagnostic Methods

• Culture vaginal discharge on fungal selective media for species identification in recurrent or complicated cases 1, 2
• Consider DNA hybridization probe tests (e.g., Affirm VP III Assay) which can detect Candida albicans 1, 2
• Quantitative Gram stain can help differentiate yeast infection from bacterial vaginosis 1, 3

Interpretation of Results

• Presence of yeast cells and/or pseudohyphae on microscopy strongly suggests yeast infection 1
• Normal vaginal pH (<4.5) supports diagnosis of yeast infection 1
• Absence of "whiff test" (no fishy odor with KOH) helps differentiate from bacterial vaginosis 1, 3
• Not all Candida species form pseudohyphae (e.g., C. glabrata), so yeast cells alone may be seen 1

Treatment Recommendations

First-Line Treatment

• For uncomplicated vulvovaginal candidiasis:
  • Topical azoles (clotrimazole, miconazole, terconazole) for 3-7 days 1
  • Single-dose oral fluconazole 150 mg 1

Alternative Treatments

• Topical nystatin 100,000 units daily for 14 days 1
• For recurrent or complicated infections, longer courses of therapy may be needed 1, 2

Special Considerations

• Species identification and susceptibility testing are recommended for recurrent/complicated cases 1, 2
• Patients with prior azole exposure may benefit from susceptibility testing 1
• Self-diagnosis of vulvovaginitis is unreliable; microscopic confirmation is required to avoid unnecessary treatments 1
• Wet mount examination should be read as soon as the pelvic examination is completed to increase the likelihood of detecting motile trichomonads 1

Common Pitfalls

• Relying solely on clinical symptoms without microscopic confirmation can lead to misdiagnosis, as symptoms of different vaginal infections may overlap 3
• Saline microscopy and KOH preparations can have false-negative and false-positive results 3
• Not all Candida infections present with the classic white discharge; some may present with erythema or minimal discharge 1
• Failure to identify non-albicans Candida species may lead to treatment failures, as some species have reduced susceptibility to azoles 1, 2

By following this systematic approach to diagnosis and treatment, clinicians can accurately identify and effectively manage vaginal yeast infections in the office setting.