What is the best course of treatment for a female patient with a history of urinary tract infections (UTIs) and yeast infections, who is experiencing swelling of the external vulva and a burning sensation when urine comes into contact with the skin?

Vulvar Swelling and Burning with Urinary Contact: Diagnostic and Treatment Approach

This presentation of external vulvar swelling with burning when urine contacts the skin most likely represents vulvovaginal candidiasis with external vulvar involvement, and should be treated with topical azole therapy for 7-14 days given the severity of symptoms. 1

Primary Diagnosis and Rationale

The constellation of vulvar swelling and burning specifically triggered by urinary contact points strongly toward vulvovaginal candidiasis with external vulvar inflammation. 1 This is critical to understand: vulvovaginal candidiasis characteristically affects both vaginal and vulvar tissues simultaneously, with erythema, pruritus, and inflammation extending beyond the vaginal mucosa to the external genital skin. 1

External dysuria (burning when urine touches skin) is pathognomonic for vulvar skin inflammation, distinguishing this from internal urinary tract pathology. 1 This occurs when urine contacts inflamed vulvar skin surfaces, not from urethral or bladder involvement. 1

Diagnostic Confirmation Required

Before initiating treatment, you must obtain:

• Wet-mount preparation with 10% KOH to visualize yeast or pseudohyphae—clinical appearance alone is insufficient for diagnosis 1
• Vaginal pH measurement—should be ≤4.5; elevated pH suggests bacterial vaginosis or trichomoniasis instead 1
• Physical examination specifically assessing for vulvar erythema, edema, satellite lesions, and white discharge 1

Critical pitfall: Self-diagnosis of yeast infection is unreliable—microscopic confirmation must be obtained before treatment. 1 Do not treat based on symptoms alone.

First-Line Treatment Protocol

For uncomplicated vulvovaginal candidiasis with significant vulvar involvement:

• Topical azole therapy for 7-14 days is preferred over single-dose treatments when vulvar inflammation is severe 1
  • Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1, OR
  • Miconazole 2% cream 5g intravaginally daily for 7 days 1, OR
  • Terconazole 0.4% cream 5g intravaginally daily for 7 days 1

Alternative oral option: Fluconazole 150 mg orally as single dose achieves >90% efficacy for uncomplicated cases 1, though extended topical therapy may be preferable given the prominent external symptoms.

The intravaginal topical preparations treat both vaginal and vulvar skin involvement simultaneously—separate external application is typically unnecessary. 1

Symptomatic Relief Measures

While awaiting antifungal effect:

• Topical hydrocortisone may be applied to external vulvar skin not more than 3-4 times daily for symptomatic relief of inflammation 2
• However, do not use hydrocortisone in the genital area if vaginal discharge is present without first consulting a physician 2
• Avoid contact with eyes and do not use for more than 7 days without medical supervision 2

Alternative Diagnoses to Consider

If microscopy is negative for candidiasis or symptoms fail to respond:

Lichen Sclerosus

• Look for porcelain-white plaques, fragile atrophic skin, and fissures in figure-eight pattern around vulva and anus 3, 4
• Most common in postmenopausal women, characterized by intractable pruritus and dyspareunia 3
• Requires biopsy if diagnosis uncertain 3
• First-line treatment: ultrapotent topical corticosteroids (clobetasol propionate 0.05%) with long-term maintenance 4

Vulvodynia/Dysesthetic Vulvodynia

• Burning pain without visible depigmentation or structural changes 3
• Diagnosis of exclusion after ruling out infectious and inflammatory causes 5, 6

Contact Dermatitis

• Consider if there is history of new soaps, detergents, or hygiene products 7

When to Escalate Care

Re-evaluate if:

• Symptoms persist beyond 7 days of appropriate therapy 2
• Symptoms recur within 2 months 1
• Microscopy reveals no yeast but symptoms continue 1

For recurrent vulvovaginal candidiasis (≥4 episodes/year):

• Initial induction: 10-14 days topical azole or oral fluconazole 1
• Maintenance: Fluconazole 150 mg weekly for 6 months achieves control in >90% of patients 1

Critical Management Points

• Do not treat asymptomatic colonization—10-20% of women normally harbor Candida without infection 1
• Vulvovaginal candidiasis can occur concomitantly with STDs—maintain appropriate clinical suspicion and testing when indicated 1
• Avoid fluconazole in pregnancy—use only 7-day topical azole therapy 1
• Single-dose treatments should be reserved for mild-to-moderate uncomplicated cases only 1