Should a female patient with dysuria, vaginal pruritus, and cottage cheese vaginal discharge, and a urinalysis (UA) showing leukocytosis and hematuria but negative for nitrites, be treated for both a yeast infection and a urinary tract infection (UTI)?

Treatment Recommendation: Yeast Infection Only

Treat this patient for vulvovaginal candidiasis alone; the urinalysis findings do not indicate a urinary tract infection (UTI) in the presence of classic vaginal yeast symptoms and vaginal discharge. 1

Clinical Reasoning

The key diagnostic principle here is that the presence of vaginal discharge substantially decreases the likelihood of UTI and points toward a vaginal source of symptoms. 1 The 2024 European Association of Urology guidelines explicitly state that uncomplicated cystitis can be diagnosed "on the basis of a focused history of lower urinary tract symptoms (dysuria, frequency, and urgency) and the absence of vaginal discharge." 1

Why the Urinalysis Findings Are Misleading

• Leukocytes in urine can originate from vaginal contamination, especially when cottage cheese discharge is present. 2, 3
• Negative nitrites are highly significant: Nitrites are the most specific dipstick component for bacterial UTI, particularly when positive. 2 Their absence argues strongly against bacterial cystitis caused by typical uropathogens like E. coli. 1
• Pyuria without bacteriuria is common in non-infectious conditions, including vaginal contamination of the urine specimen. 1, 2
• Hematuria can occur with vaginal candidiasis due to local irritation and inflammation of the vulvovaginal tissues. 3

The Clinical Picture Points to Candidiasis

The triad of symptoms presented is pathognomonic for vulvovaginal candidiasis:

• Vaginal pruritus (itching) 4
• Cottage cheese discharge (thick white vaginal discharge characteristic of yeast) 4
• Dysuria in this context likely represents external dysuria from urine contacting inflamed vulvar tissues, not internal urethral/bladder pain 3

Recommended Treatment

Prescribe fluconazole 150 mg as a single oral dose for uncomplicated vulvovaginal candidiasis. 4, 5

Alternative Options

• Topical azole antifungals (e.g., miconazole, clotrimazole) for 1-7 days if oral therapy is contraindicated 5
• Fluconazole is the treatment of choice because it achieves high tissue levels and is highly effective for symptomatic vaginal yeast infections 4, 5

When to Reconsider UTI Treatment

Obtain a urine culture if symptoms persist or worsen after treating the yeast infection. 1 The 2024 EAU guidelines recommend urine culture for:

• Women who present with atypical symptoms 1
• Symptoms that do not resolve or recur within 4 weeks after completion of treatment 1

If the patient develops fever, flank pain, or systemic symptoms, this would indicate possible pyelonephritis requiring immediate urine culture and empiric antibiotics. 1

Common Pitfalls to Avoid

• Do not reflexively treat positive urinalysis without considering the clinical context. The presence of vaginal discharge fundamentally changes the interpretation. 1, 3
• Do not assume all dysuria equals UTI. External dysuria from vulvovaginal inflammation mimics UTI symptoms but requires different treatment. 3
• Avoid obtaining urine culture through voided specimen when vaginal discharge is present, as contamination is inevitable. If UTI workup is truly needed, consider catheterized specimen. 1
• Do not treat asymptomatic bacteriuria if discovered incidentally—this patient has symptoms, but they are attributable to vaginal candidiasis, not bladder infection. 1

Follow-Up Considerations

• If symptoms persist after antifungal treatment, then obtain a catheterized urine culture to definitively rule out UTI. 1
• Counsel the patient that dysuria should improve within 24-48 hours as vulvovaginal inflammation resolves with antifungal therapy. 4
• Consider risk factors for recurrent candidiasis: diabetes, recent antibiotics, immunosuppression, or hormonal contraceptives. 5