What can be prescribed for an elderly female patient with impaired renal function on hemodialysis (HD) who complains of vaginal itching with discharge?

Management of Vaginal Itching with Discharge in an Elderly Female on Hemodialysis

For an elderly female on hemodialysis presenting with vaginal itching and discharge, you should first perform a speculum examination with vaginal pH testing and microscopy to diagnose the specific infection (bacterial vaginosis, candidiasis, or trichomoniasis), then treat accordingly while also addressing underlying atrophic vaginitis with vaginal estrogen therapy. 1, 2

Diagnostic Approach

The three most common causes of vaginal discharge with itching are:

• Vulvovaginal candidiasis (fungal infection, usually Candida albicans)
• Bacterial vaginosis (anaerobic bacterial overgrowth)
• Trichomoniasis (protozoal infection with Trichomonas vaginalis) 1, 3

Essential Diagnostic Steps

• Perform vaginal pH testing using narrow-range pH paper—a pH >4.5 suggests bacterial vaginosis or trichomoniasis, while pH <4.5 suggests candidiasis 1
• Prepare two microscopy slides: one with normal saline and one with 10% KOH solution 1
• Apply KOH to detect the "whiff test" (amine odor immediately after application suggests bacterial vaginosis) 1
• Examine the saline slide for motile Trichomonas organisms or clue cells (bacterial vaginosis) 1
• Examine the KOH slide for yeast or pseudohyphae of Candida species 1
• If microscopy is negative but symptoms persist, obtain culture for Trichomonas as it is more sensitive than microscopy 1

Treatment Based on Diagnosis

For Vulvovaginal Candidiasis (Most Likely Given Itching as Primary Symptom)

Fluconazole 150 mg orally as a single dose is the preferred treatment 4, 5

• In patients on hemodialysis, administer 100% of the recommended dose (150 mg) after each hemodialysis session 4
• On non-dialysis days, no additional dosing is needed for single-dose vaginal candidiasis treatment 4
• Alternative topical options include intravaginal azole antifungals if oral therapy is contraindicated 1

For Bacterial Vaginosis

• Treat with metronidazole or clindamycin (specific regimens per CDC guidelines) 1
• Dose adjustment may be needed based on hemodialysis schedule 4

For Trichomoniasis

• Treat with metronidazole (specific regimens per CDC guidelines) 1
• This is a sexually transmitted infection, so evaluate and treat sexual partners 1

Critical Additional Management: Atrophic Vaginitis

Regardless of the acute infection identified, this elderly patient likely has underlying atrophic vaginitis due to estrogen deficiency, which is a major risk factor for both vaginal infections and recurrent UTIs. 1, 2

Vaginal Estrogen Therapy

• Prescribe vaginal estrogen cream (estriol 0.5 mg) applied nightly for 2 weeks, then twice weekly for maintenance 6, 7
• Vaginal estrogen restores vaginal pH, reestablishes lactobacilli colonization, and reverses atrophic changes 6
• This therapy has minimal systemic absorption and does not require progesterone co-administration even in women with a uterus 7
• Continue therapy for at least 6-12 months for optimal outcomes 6

Special Considerations for Hemodialysis Patients

Medication Dosing Adjustments

• For fluconazole in hemodialysis patients: give 100% of the recommended dose after each dialysis session 4
• On non-dialysis days, patients should receive reduced doses according to their creatinine clearance for multi-dose regimens 4
• Single-dose therapy for vaginal candidiasis does not require adjustment beyond post-dialysis timing 4

Differential Diagnosis Pitfall

• Do not confuse vaginal itching with uremic pruritus, which affects 70-74% of hemodialysis patients but typically involves the back and legs, not specifically the vaginal area 8, 9
• Uremic pruritus is generalized in 65.7% of cases and would not be associated with vaginal discharge 9

Prevention of Recurrence

• Vaginal estrogen therapy is the most effective preventive intervention, reducing recurrence by 75% in postmenopausal women 6, 7
• Consider adding lactobacillus-containing probiotics (vaginal or oral) to enhance vaginal flora restoration 6
• Avoid harsh vaginal cleansers that disrupt normal flora 6

Common Pitfalls to Avoid

• Do not treat empirically without proper diagnosis—the three main causes require different treatments 1, 3
• Do not overlook atrophic vaginitis as the underlying predisposing factor in elderly women 1, 2
• Do not forget to adjust medication dosing for hemodialysis patients to avoid toxicity or treatment failure 4
• Do not attribute vaginal symptoms to uremic pruritus without proper examination, as this would lead to missed diagnosis of treatable vaginal infections 8, 9