Differential Diagnosis for Vulvar Pruritus and Vaginal Discharge
- Single most likely diagnosis:
- Vulvovaginal candidiasis: This is the most likely diagnosis given the patient's symptoms of vulvar pruritus, frequent urination, dysuria, and nocturia, along with the presence of thick, white discharge and pseudohyphae on microscopy. The patient's history of recurrent symptoms that were temporarily relieved by over-the-counter suppositories, which are often antifungal, further supports this diagnosis.
- Other Likely diagnoses:
- Bacterial vaginosis: Although the microscopy did not reveal motile organisms, bacterial vaginosis could still be considered, especially if the patient's symptoms do not fully resolve with antifungal treatment. However, the presence of pseudohyphae strongly suggests a fungal infection.
- Atrophic vaginitis: Given the patient's age and symptoms of dysuria and nocturia, atrophic vaginitis could be a contributing factor, especially if the patient is experiencing hormonal changes. However, the primary symptoms and microscopy findings point more towards an infectious cause.
- Do Not Miss diagnoses:
- Diabetes mellitus: It is crucial to consider diabetes mellitus in a patient presenting with recurrent fungal infections, as diabetes can predispose individuals to such infections. Although the patient's blood pressure and BMI are noted, her fasting glucose level is not provided, making it essential to rule out diabetes.
- Sexually transmitted infections (STIs): While the patient reports being in a long-term, monogamous relationship, it is still important to consider STIs, such as trichomoniasis or gonorrhea, especially if the patient's symptoms do not respond to antifungal treatment. The absence of motile organisms on microscopy makes trichomoniasis less likely but does not rule it out entirely.
- Rare diagnoses:
- Lichen sclerosis: This is a rare condition that can cause vulvar pruritus and skin changes. However, it would not typically cause the vaginal discharge described, and the presence of pseudohyphae points more strongly towards a fungal infection.
- Vulvar dermatitis or eczema: These conditions could cause vulvar pruritus and erythema but would not account for the vaginal discharge or the microscopy findings of pseudohyphae.