What is the appropriate initial evaluation and treatment for an 18-year-old female presenting with spontaneous vulvar swelling and milky discharge without odor?

Evaluation and Management of Spontaneous Vulvar Swelling with Milky Discharge in an 18-Year-Old

This presentation most likely represents vulvovaginal candidiasis or bacterial vaginosis, and you should perform immediate office-based microscopy with saline and 10% KOH preparations along with vaginal pH testing to differentiate between these conditions before initiating treatment. 1

Initial Diagnostic Approach

Perform the following bedside tests immediately:

• Wet mount microscopy: Dilute vaginal discharge in 1-2 drops of 0.9% normal saline on one slide and 10% KOH on a second slide 2
• Vaginal pH measurement: pH <4.5 suggests candidiasis; pH >4.5 suggests bacterial vaginosis or trichomoniasis 1, 3
• Whiff test: Apply 10% KOH to discharge—a fishy odor indicates bacterial vaginosis or trichomoniasis 2, 1
• Visual inspection: Examine for vulvar erythema, swelling, and discharge characteristics 2

Key Diagnostic Features to Identify

For Vulvovaginal Candidiasis:

• Microscopy findings: Yeasts or pseudohyphae visible on KOH preparation 3
• Vaginal pH: Normal (<4.5) 3, 4
• Clinical presentation: Pruritus and vulvar erythema are the primary diagnostic features; white discharge may or may not be present 3
• Whiff test: Negative 1

For Bacterial Vaginosis (Amsel Criteria - need 3 of 4):

• Homogeneous white/gray discharge adhering to vaginal walls 2, 1
• Clue cells on saline microscopy 2, 1
• Vaginal pH >4.5 2, 1
• Positive whiff test (fishy odor with KOH) 2, 1

Critical Clinical Pitfall

Do not treat based on clinical appearance alone—the CDC explicitly warns that 10-20% of women normally harbor Candida without symptoms, and milky discharge is non-specific for any single condition 1, 3. The absence of odor in your patient does NOT rule out bacterial vaginosis, as up to 50% of women with BV meeting diagnostic criteria are asymptomatic 5.

Treatment Based on Confirmed Diagnosis

If Vulvovaginal Candidiasis Confirmed:

First-line treatment (80-90% efficacy): 1, 3

• Oral fluconazole 150 mg single dose, OR
• Clotrimazole 1% cream 5g intravaginally for 7-14 days, OR
• Miconazole 2% cream 5g intravaginally for 7 days, OR
• Terconazole 0.8% cream 5g intravaginally for 3 days 1

If Bacterial Vaginosis Confirmed:

Recommended regimen: 2, 1, 5

• Metronidazole 500 mg orally twice daily for 7 days (cure rate 80-90%) 5
• Counsel patient to avoid alcohol during treatment and for 24 hours after completion 2

Alternative regimens: 1

• Metronidazole gel 0.75% intravaginally once daily for 5 days, OR
• Clindamycin 2% cream intravaginally at bedtime for 7 days

Additional Evaluation for Vulvar Swelling

Examine specifically for: 2

• Bartholin gland infection: Located at 4 and 8 o'clock positions in posterior vestibule; presents with swelling, erythema, and tenderness extending into labia minora 2
• Folliculitis: Particularly common with pubic hair shaving; counsel on proper technique with adequate lubrication 2
• STI screening: If Bartholin gland infection present, test for gonorrhea and chlamydia as these commonly infect these glands 2

Follow-Up Considerations

• For candidiasis: Return only if symptoms persist or recur within 2 months 2
• For bacterial vaginosis: Warn patient about 50-80% recurrence rate within one year; may require repeated courses 1, 5
• If initial testing negative but symptoms persist: Consider retesting for BV using Gram stain or DNA probe (90% sensitivity), as standard testing misses 20-30% of cases 5