What are the treatment options for vaginal irritation, burning, and abnormal discharge?

Treatment of Vaginal Irritation, Burning, and Abnormal Discharge

The treatment depends on the specific cause identified through pH testing and microscopic examination, with topical azoles for candidiasis, oral metronidazole for bacterial vaginosis or trichomoniasis, and partner treatment required only for trichomoniasis. 1, 2

Diagnostic Approach Before Treatment

You must establish the diagnosis before initiating therapy by measuring vaginal pH and performing microscopic examination of the discharge. 2

Key Diagnostic Steps:

• Vaginal pH >4.5 suggests bacterial vaginosis or trichomoniasis 3
• Vaginal pH ≤4.5 indicates vulvovaginal candidiasis 3
• Saline wet mount identifies motile trichomonads (trichomoniasis) or clue cells (bacterial vaginosis) 3, 2
• 10% KOH preparation reveals yeast or pseudohyphae (candidiasis) by disrupting cellular material 3

Treatment by Specific Diagnosis

Vulvovaginal Candidiasis (VVC)

For uncomplicated VVC (mild-to-moderate, sporadic, non-recurrent), use short-course topical azoles or single-dose oral fluconazole. 3

First-Line Topical Options:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
• Miconazole 2% cream 5g intravaginally for 7 days 3
• Terconazole 0.4% cream 5g intravaginally for 7 days 3
• Butoconazole 2% cream 5g intravaginally for 3 days 3

Oral Alternative:

• Fluconazole 150mg single oral dose 3, 4

For Complicated/Recurrent VVC (≥4 episodes/year):

• Initial therapy: 7-14 days of topical azole OR fluconazole 150mg repeated after 3 days 1
• Maintenance regimen: Fluconazole 150mg once weekly for 6 months 1, 2

Critical caveat: Approximately 10-20% of women harbor Candida asymptomatically; do not treat positive cultures without symptoms. 3, 2

Bacterial Vaginosis (BV)

BV is diagnosed when three of four Amsel criteria are present: homogeneous white discharge, vaginal pH >4.5, positive whiff test, and clue cells on microscopy. 3, 2

Recommended Treatment:

• Oral metronidazole 500mg twice daily for 7 days 5, 6
• Alternative: Intravaginal metronidazole or clindamycin 6

Do not treat male sexual partners—this does not prevent recurrence. 3, 2

Trichomoniasis

Trichomoniasis presents with yellow-green, malodorous discharge and requires treatment of both patient and all sexual partners. 3, 1

Standard Treatment:

• Metronidazole 2g single oral dose 1, 5
• Alternative: Metronidazole 500mg twice daily for 7 days 5

Essential: Treat all sexual partners simultaneously to prevent reinfection. 3, 1

Special Population Considerations

Pregnancy:

• Use only 7-day topical azole therapy for VVC; avoid oral fluconazole 1, 2
• Metronidazole 2g single dose is safe for trichomoniasis in pregnancy 3

HIV-Infected Patients:

• Treat with identical regimens as HIV-negative patients 3, 1

Recurrent Infections:

• Verify therapeutic compliance and rule out reinfection from untreated partners 1
• Check for host factors: uncontrolled diabetes, immunosuppression, or pregnancy 1

Critical Pitfalls to Avoid

• Never recommend self-medication except for women previously diagnosed with VVC experiencing identical symptoms 3, 2
• Do not treat asymptomatic Candida colonization 3, 2
• For recurrent VVC, do not omit the 6-month maintenance regimen after initial treatment 1
• Avoid vaginal douching as it disrupts normal flora 2
• Do not use oral fluconazole in pregnancy 1

Follow-Up Protocol

Patients should return only if symptoms persist after treatment or recur within 2 months. 3, 2 For women using over-the-counter preparations who experience persistent or recurrent symptoms, medical evaluation is mandatory. 3