What is the likely diagnosis and treatment for labia pain, redness, swelling, and white runny discharge?

Likely Diagnosis and Treatment for Labia Pain, Redness, Swelling, and White Discharge

The most likely diagnosis is vulvovaginal candidiasis (yeast infection), and you should treat with either oral fluconazole 150 mg as a single dose or a topical azole antifungal for 3-7 days. 1, 2, 3

Clinical Reasoning

The combination of labia pain, redness, swelling (vulvar inflammation), and white discharge strongly suggests vulvovaginal candidiasis rather than bacterial vaginosis or trichomoniasis. 1, 2

Key distinguishing features:

• Vulvar inflammation (pain, redness, swelling) is characteristic of candidiasis but notably absent in bacterial vaginosis, which produces a "noninflammatory" discharge. 1, 4
• White discharge can occur with candidiasis (though not always present), whereas bacterial vaginosis typically produces a homogeneous gray-white discharge with fishy odor. 1, 2
• The presence of significant vulvar symptoms (pain, burning, swelling) points away from bacterial vaginosis, which primarily causes vaginal discharge without vulvar involvement. 1, 4

Diagnostic Confirmation

Before treating, confirm the diagnosis with:

• Vaginal pH testing: Candidiasis has normal pH (≤4.5), while bacterial vaginosis has pH >4.5. 1, 2
• Wet mount with 10% KOH: Look for yeasts or pseudohyphae, which confirms candidiasis in 50-70% of cases. 1, 2, 5
• Whiff test: Should be negative in candidiasis (positive fishy odor suggests bacterial vaginosis). 1, 4

Important caveat: If microscopy is negative but clinical suspicion remains high, culture is more sensitive than microscopic examination and should be obtained. 2

Treatment Recommendations

First-Line Options:

Oral therapy (most convenient):

• Fluconazole 150 mg orally as a single dose 1, 3

Topical intravaginal therapy (equally effective, 80-90% cure rate):

• Clotrimazole 1% cream 5g intravaginally for 7 days, OR 1
• Miconazole 2% cream 5g intravaginally for 7 days, OR 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1

Shorter courses for mild-to-moderate cases:

• Clotrimazole 100 mg vaginal tablet, two tablets for 3 days, OR 1
• Miconazole 200 mg vaginal suppository for 3 days 1

Treatment Selection:

• Severe symptoms (significant vulvar inflammation): Use 7-day topical regimens rather than single-dose treatments. 1
• Pregnancy: Use only topical azoles; avoid oral fluconazole. 3, 6
• Over-the-counter availability: Clotrimazole and miconazole are available without prescription. 1, 7

Critical Pitfalls to Avoid

Do not treat based on appearance alone without diagnostic confirmation. 2 Approximately 10-20% of asymptomatic women harbor Candida species in the vagina, and identifying yeast without symptoms should not lead to treatment. 1, 2

Consider alternative diagnoses if:

• pH is >4.5 (suggests bacterial vaginosis or trichomoniasis, not candidiasis) 1, 2
• Fishy odor is present (bacterial vaginosis) 1, 4
• Minimal discharge with vulvar inflammation suggests mechanical, chemical, or allergic irritation rather than infection 1

Recurrent infections (>3 episodes per year): May indicate diabetes, immunosuppression, or non-albicans Candida species requiring culture and potentially longer treatment courses. 5, 6

Partner Management

Partner treatment is not necessary for vulvovaginal candidiasis, as it is not considered a sexually transmitted infection. 1, 8 This distinguishes it from trichomoniasis and bacterial vaginosis in certain contexts.

Follow-Up

No follow-up is needed if symptoms resolve completely. 1 If symptoms persist beyond 3 days or worsen, re-evaluate for treatment failure, resistant organisms, or alternative diagnoses. 7, 6