What is the appropriate treatment for a patient presenting with brown vaginal discharge suspected to be a yeast infection?

Brown Vaginal Discharge and Suspected Yeast Infection

Brown vaginal discharge is not characteristic of yeast infection and requires proper diagnostic evaluation before treatment, as candidiasis typically presents with thick white "cottage cheese-like" discharge, not brown discharge. 1, 2

Critical Diagnostic Distinction

Brown vaginal discharge suggests the presence of blood (old blood appears brown) and is not a typical presentation of vulvovaginal candidiasis. The classic presentation of yeast infection includes:

• Thick, white, "curdled" or "cottage cheese-like" discharge 3
• Vulvar pruritus and irritation 4
• Normal vaginal pH (3.8-4.5) 1, 2
• Absence of foul odor 4

Brown discharge more commonly indicates:

• Bacterial vaginosis (which can have brownish discharge with elevated pH >4.5) 4
• Trichomoniasis 4
• Cervicitis from sexually transmitted infections 4, 5
• Physiologic causes (menstrual blood, ovulation spotting) 5

Diagnostic Approach

Perform a pelvic examination with the following specific tests before initiating treatment: 4, 6

1. Vaginal pH testing - Use narrow-range pH paper on vaginal secretions 4

   • Normal pH (≤4.5) suggests candidiasis 1, 2
   • Elevated pH (>4.5) indicates bacterial vaginosis or trichomoniasis 4

2. Wet mount microscopy - Examine vaginal discharge in saline 4, 6

   • Look for budding yeast or pseudohyphae (present in 50-70% of candidiasis cases) 1, 3
   • Check for motile trichomonads 4
   • Identify clue cells (bacterial vaginosis) 4

3. KOH preparation - Add 10% potassium hydroxide to a second slide 4, 6

   • More sensitive for detecting yeast/pseudohyphae 4
   • Perform "whiff test" - fishy odor indicates bacterial vaginosis or trichomoniasis 4

4. Vaginal culture - If microscopy is negative but symptoms persist 1, 2

Treatment Algorithm

If Confirmed Candidiasis (After Diagnostic Testing):

First-line treatment options (both achieve >90% cure rates): 1, 2

• Fluconazole 150 mg oral tablet as a single dose 1, 2, 7
  • Most convenient with excellent compliance 1
  • Avoid in pregnancy (associated with spontaneous abortion and congenital malformations) 2
  • May cause nausea (7%), headache (13%), abdominal pain (6%) 7

OR

• Topical azole therapy for 1-7 days 1, 2
  • Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 2
  • Miconazole 2% cream 5g intravaginally daily for 7 days 2
  • Terconazole 0.4% cream 5g intravaginally daily for 7 days 2
  • Oil-based formulations may weaken latex condoms 1

If Bacterial Vaginosis or Trichomoniasis:

• Metronidazole 500 mg orally twice daily for 7 days (bacterial vaginosis) 4
• Metronidazole 2g orally as single dose (trichomoniasis) 3
• Avoid alcohol during and 24 hours after metronidazole 4

Critical Pitfalls to Avoid

• Do not treat based on symptoms alone - brown discharge is not specific for any single etiology and requires microscopic confirmation 4, 6
• Do not assume all vaginal discharge is yeast infection - only 30-40% of women who self-diagnose yeast infection are correct 1, 2
• Do not treat asymptomatic colonization - 10-20% of women harbor Candida without infection 1, 2
• Do not advise over-the-counter self-treatment unless the patient has been previously diagnosed with identical symptoms 1, 2
• Do not ignore concurrent infections - vaginitis may be present with sexually transmitted diseases 2

Follow-Up Recommendations

• Instruct patient to return only if symptoms persist after treatment or recur within 2 months 1
• If symptoms persist: obtain vaginal culture to identify non-albicans species or resistant organisms 1, 2
• For recurrent infections (≥4 episodes/year): consider induction therapy (10-14 days) followed by maintenance fluconazole 150 mg weekly for 6 months 1, 2