What is the appropriate diagnosis and treatment for a 19-year-old female presenting with vaginal discharge, intense pruritus, dysuria, and vulvar soreness?

Diagnosis and Treatment of Vaginal Discharge with Pruritus and Dysuria

This patient most likely has vulvovaginal candidiasis (VVC) and should be treated with topical azole therapy for 7 days, with concurrent evaluation and treatment for possible sexually transmitted infections given her partner's high-risk occupation and her recurrent symptoms. 1

Diagnostic Approach

The clinical presentation strongly suggests VVC, characterized by:

• Intense pruritus (the hallmark symptom) 1
• Vulvar soreness 1
• Dysuria (external dysuria from vulvar inflammation) 1
• Vaginal discharge (typically white, though not always present) 1

However, given her husband's occupation as a lorry driver with frequent travel and her recurrent episodes since marriage, concurrent STI evaluation is essential. 1

Key Diagnostic Steps:

• Vaginal pH testing: VVC is associated with normal pH (<4.5), while trichomoniasis and bacterial vaginosis show pH >4.5 1
• Wet mount with KOH preparation: Visualizes yeast or pseudohyphae; KOH disrupts cellular material to improve visualization 1
• Saline wet mount: Evaluates for motile Trichomonas vaginalis and clue cells of bacterial vaginosis 1
• Testing for N. gonorrhoeae and C. trachomatis: Mandatory given the epidemiologic risk factors 1

Common pitfall: Approximately 70% of chlamydia and trichomoniasis infections are asymptomatic, so symptoms alone cannot exclude these diagnoses. 2

Treatment Algorithm

For Vulvovaginal Candidiasis (Primary Diagnosis):

Recommended regimen for severe VVC:

• Topical azole therapy for 7 days (not short-course therapy, given severity) 1
• Options include:
  • Butoconazole 2% cream 5g intravaginally for 3 days 1
  • Clotrimazole 1% cream applied twice daily for 7 days 3
  • Other azole preparations per CDC guidelines 1

Cure rates with azole therapy: 80-90% when therapy is completed 1

Critical consideration: Oral fluconazole is an alternative but requires careful consideration. 4 The FDA label indicates fluconazole is effective for vaginal yeast infections, but topical therapy is preferred for severe presentations. 1, 4

For Concurrent STI Coverage:

Given the epidemiologic risk (partner with frequent travel, recurrent episodes since marriage), empiric treatment should include:

1. For possible trichomoniasis (which can present with intense pruritus and dysuria):

   • Metronidazole 500 mg orally twice daily for 7 days 1, 5
   • This is superior to single-dose therapy for symptomatic patients 5
   • Cure rates: 90-95% 1

2. For possible chlamydia:

   • Doxycycline 100 mg orally twice daily for 7 days 5, 2, 6
   • This is now preferred over azithromycin per 2021 CDC guidelines 5

3. For possible gonorrhea:

   • Ceftriaxone 500 mg IM single dose (for patients <150 kg) 5, 6
   • Azithromycin is no longer recommended as dual therapy due to resistance concerns 6

Management of Sex Partner

The husband must be evaluated and treated presumptively 1:

• Partners should be treated if last sexual contact was within 30 days of symptom onset 1
• Instruct the patient to abstain from sexual intercourse until both partners complete therapy and are asymptomatic 1
• Partner treatment is essential even for VVC when recurrent episodes suggest possible reinfection 1

Follow-Up Recommendations

• Return for evaluation if symptoms persist or recur within 2 months 1
• If this represents recurrent VVC (≥4 episodes per year), this is classified as "complicated VVC" requiring longer initial therapy and maintenance regimens 1
• Test-of-cure is not routinely needed for uncomplicated VVC but is essential for trichomoniasis if treated 1

Special Considerations and Pitfalls

Common diagnostic error: Treating based on symptoms alone without microscopy leads to misdiagnosis in up to 50% of cases, as symptoms of VVC, trichomoniasis, and bacterial vaginosis overlap significantly. 1

Recurrent episodes warrant investigation for:

• Uncontrolled diabetes 1
• HIV infection (though treatment regimens remain the same) 1
• Non-albicans Candida species (requires culture and potentially different azole therapy) 1
• Reinfection from untreated partner 1

The severity of this episode and recurrent nature since marriage strongly suggests either inadequate initial treatment, partner reinfection, or an underlying predisposing condition that requires evaluation. 1