What is the appropriate management for a sexually active female patient with a history of vaginal infections, experiencing dysuria and vulvar pruritus, considering potential diagnoses such as UTI or vulvovaginal candidiasis?

Treatment of Dysuria and Vulvar Pruritus in Sexually Active Women

For a sexually active woman with dysuria and vulvar itching, first-line treatment is fluconazole 150 mg orally as a single dose or a short-course topical azole (1-3 days) for presumed vulvovaginal candidiasis, which achieves 80-90% cure rates. 1, 2

Diagnostic Confirmation Before Treatment

While empiric treatment is often appropriate, confirm the diagnosis when possible:

• Check vaginal pH: Normal pH (<4.5) supports candidiasis; elevated pH (>4.5) suggests bacterial vaginosis or trichomoniasis 1, 2
• Perform wet mount with KOH preparation: Visualization of yeast, pseudohyphae, or budding yeast cells confirms vulvovaginal candidiasis 1
• Assess discharge characteristics: White, thick, curd-like discharge with vulvar erythema, edema, and excoriation indicates candidiasis 1
• Rule out sexually transmitted infections: If mucopurulent cervical discharge is present or patient has new/multiple partners, test for Chlamydia trachomatis and Neisseria gonorrhoeae 1, 2

Critical pitfall: External dysuria (burning when urine touches inflamed vulvar skin) differs from internal dysuria (urethral/bladder pain), which suggests urinary tract infection rather than vulvovaginal candidiasis. 3

First-Line Treatment Options

Oral Therapy

• Fluconazole 150 mg single oral dose achieves clinical cure in 69% and therapeutic cure (clinical + mycologic eradication) in 55% of patients 4, 1

Topical Therapy (Equally Effective)

Multiple over-the-counter and prescription options are available 1, 2:

Short-course regimens (1-3 days):

• Miconazole 1200 mg vaginal suppository as single dose 5, 1
• Miconazole 4% cream 5g intravaginally daily for 3 days 1
• Terconazole 0.8% cream 5g intravaginally daily for 3 days 1, 2
• Clotrimazole 2% cream 5g intravaginally daily for 3 days 1

Longer-course regimens (7-14 days):

• Clotrimazole 1% cream 5g intravaginally daily for 7-14 days 1, 2
• Miconazole 2% cream 5g intravaginally daily for 7 days 1, 2

External Vulvar Cream for Symptom Relief

• Apply miconazole 2% cream externally to vulva twice daily for up to 7 days for relief of external itching and irritation 5
• This addresses vulvar symptoms while the vaginal treatment eradicates the infection 5

Special Populations and Complicated Cases

Pregnancy

Use only topical azoles for 7 days in pregnant women; oral fluconazole is contraindicated due to associations with spontaneous abortion and congenital defects. 1, 2

Recurrent Vulvovaginal Candidiasis (≥4 Episodes/Year)

This requires a two-phase approach 1, 2:

1. Induction therapy: Topical azole or oral fluconazole for 10-14 days 1
2. Maintenance therapy: Fluconazole 150 mg weekly for 6 months, which achieves symptom control in >90% of patients 1, 2

Important caveat: After stopping maintenance therapy, expect 40-50% recurrence rate; evaluate for predisposing conditions including diabetes, immunosuppression, HIV, and antibiotic use. 1, 2

Severe or Complicated Infection

For severe vulvovaginal candidiasis (extensive vulvar erythema, edema, excoriation, fissures):

• Extend treatment to 5-7 days with topical agents OR fluconazole 150 mg every 72 hours for 3 doses (total of 3 doses) 1

When to Suspect Alternative Diagnoses

Reconsider the diagnosis if symptoms do not improve within 3 days or persist beyond 7 days 5, 6:

• Bacterial vaginosis: Thin, gray discharge with fishy odor, pH >4.5, clue cells on microscopy 2, 3
• Trichomoniasis: Yellow-green malodorous discharge, pH >4.5, motile trichomonads on wet mount 2, 3
• Cervicitis/PID: Mucopurulent cervical discharge, cervical motion tenderness, uterine/adnexal tenderness require broader antibiotic coverage for N. gonorrhoeae and C. trachomatis 1, 7
• Desquamative inflammatory vaginitis: Purulent discharge, elevated pH, requires topical clindamycin and steroids 3, 8

Treatment Precautions

Avoid during treatment 5:

• Tampons (remove medication from vagina)
• Douches (remove medication)
• Spermicides (interfere with treatment)
• Condoms and diaphragms (may be damaged by azole products, leading to contraceptive failure)
• Vaginal intercourse (until treatment complete)

Drug interaction warning: Patients taking warfarin should consult a physician before using azole antifungals due to increased bleeding risk. 5

Follow-Up and Partner Management

• Partners do not require treatment for vulvovaginal candidiasis unless they have symptomatic balanitis (penile rash, itching, irritation) 1, 9
• If symptoms persist or worsen, return for re-evaluation within 3 days to rule out treatment failure or alternative diagnosis 5, 6
• Consider vaginal culture to identify non-albicans species (C. glabrata, C. krusei) if treatment fails, as these may require alternative therapy such as boric acid 600 mg vaginal suppositories 1, 8