How should I evaluate and treat a woman presenting with vaginal discharge and pruritus?

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Evaluation and Treatment of Vaginal Discharge with Pruritus

Perform immediate point-of-care testing with vaginal pH measurement, saline wet mount, and 10% KOH preparation to differentiate between the three most common causes: vulvovaginal candidiasis (VVC), bacterial vaginosis (BV), and trichomoniasis, then treat based on findings. 1

Diagnostic Algorithm

Step 1: Measure Vaginal pH

  • Use narrow-range pH paper at the bedside; pH ≤4.5 indicates VVC, while pH >4.5 suggests BV or trichomoniasis. 1, 2
  • This single test immediately narrows your differential and guides subsequent microscopy interpretation. 3

Step 2: Perform Saline Wet Mount

  • Examine immediately for motile trichomonads (diagnostic of trichomoniasis), clue cells (BV), and inflammatory cells. 1, 2
  • Motile trichomonads are visible in 50-75% of trichomoniasis cases; absence does not exclude the diagnosis. 4
  • Clue cells (epithelial cells with adherent bacteria obscuring borders) present in >20% of cells strongly suggest BV. 4

Step 3: Perform 10% KOH Preparation

  • Add KOH to a second sample to visualize yeast forms or pseudohyphae (diagnostic of VVC) and simultaneously perform the whiff test. 1, 2
  • Yeast or pseudohyphae are visible in only 50-70% of true VVC cases, so negative microscopy does not rule out infection if symptoms are classic. 1, 4
  • A positive whiff test (fishy odor when KOH is added) indicates BV or trichomoniasis. 3

Step 4: Assess Clinical Presentation

  • VVC typically presents with thick white "cottage cheese" discharge, intense vulvar pruritus, vulvar erythema, and normal pH. 3, 1
  • Trichomoniasis presents with yellow-green frothy discharge, malodor, vulvar irritation, and pH >4.5. 1, 5
  • BV presents with thin homogeneous gray-white discharge, fishy odor, minimal pruritus, and pH >4.5. 4, 6

Treatment Based on Diagnosis

Vulvovaginal Candidiasis (Most Common Cause of Pruritus)

For uncomplicated VVC, prescribe either oral fluconazole 150 mg as a single dose OR a topical azole for 1-7 days. 3, 1

Topical Azole Options (equally effective):

  • Clotrimazole 1% cream 5 g intravaginally daily for 7 days 3
  • Miconazole 2% cream 5 g intravaginally daily for 7 days 3
  • Terconazole 0.4% cream 5 g intravaginally daily for 7 days 3
  • Single-dose options: Clotrimazole 500 mg vaginal tablet OR Tioconazole 6.5% ointment (for mild-to-moderate disease only) 1

For Complicated VVC (recurrent, severe, non-albicans species, diabetes, immunosuppression, pregnancy):

  • Use extended topical azole therapy for 7-14 days OR fluconazole 150 mg on days 1 and 4. 3, 1
  • For recurrent VVC (≥4 episodes/year), initiate maintenance therapy with fluconazole 150 mg weekly for 6 months after achieving initial cure. 3, 1

Trichomoniasis

Prescribe metronidazole 2 g orally as a single dose (90-95% cure rate) AND treat the sexual partner simultaneously. 3, 5

  • Alternative regimen: Metronidazole 500 mg twice daily for 7 days 3
  • Tinidazole 2 g single dose is equally effective with cure rates of 92-100%. 7
  • Partner treatment is essential; treatment failure is usually due to untreated partners. 4
  • Instruct patients to avoid sexual contact until both partners complete therapy and are asymptomatic. 3

Bacterial Vaginosis (If Present with Pruritus)

Prescribe metronidazole 500 mg orally twice daily for 7 days. 1, 6

  • Alternative: Metronidazole 0.75% gel intravaginally daily for 5 days OR Clindamycin 2% cream intravaginally at bedtime for 7 days 6
  • Partner treatment is NOT recommended for BV. 1

Concurrent Infections

If both VVC and BV are present (not uncommon), treat both simultaneously with metronidazole 500 mg twice daily for 7 days PLUS either fluconazole 150 mg single dose or 7-day topical azole. 1

  • This is critical because metronidazole treatment precipitates VVC in 12.5-30% of patients. 1

Special Populations

Pregnancy

  • Use ONLY 7-day topical azole therapy for VVC; oral fluconazole is contraindicated. 3, 1, 2
  • Treat symptomatic trichomoniasis with metronidazole 2 g single dose to reduce preterm delivery risk. 3, 2
  • Metronidazole is safe in pregnancy; multiple studies show no teratogenic effects. 3

HIV-Infected Patients

  • Use identical treatment regimens as HIV-negative patients; no modification is needed. 3, 1, 2

Critical Pitfalls to Avoid

  • Never treat based solely on microscopic findings without symptoms; 10-20% of women harbor Candida as normal flora. 3, 1
  • Do not recommend OTC self-treatment unless the patient has a prior confirmed VVC diagnosis and identical recurrent symptoms. 1
  • Do not rely on symptoms alone; clinical presentation is not specific, and microscopic confirmation is essential. 1
  • If symptoms persist after OTC treatment, obtain vaginal culture to identify non-albicans Candida species (especially C. glabrata), which account for 10-20% of refractory cases and require extended therapy. 1, 4
  • Always test for coexisting STIs when clinically indicated; VVC can occur concomitantly with chlamydia or gonorrhea. 3, 1

When to Obtain Cultures

  • Obtain vaginal culture if microscopy is negative but symptoms persist, if recurrent infections occur (≥4 episodes/year), or if treatment fails. 5, 8
  • Culture identifies non-albicans species that may be azole-resistant. 4, 8

Follow-Up

  • Advise patients to return only if symptoms persist after therapy or recur within 2 months; routine test-of-cure is unnecessary if symptoms resolve. 1, 5

References

1
Guideline

Vulvovaginitis Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Diagnostic Approach to Vaginal Itching and Burning

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Practical Guide to Diagnosing and Treating Vaginitis.

Medscape women's health, 1997

5
Guideline

Diagnostic Approach for Yellow Vaginal Discharge with Pruritus

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Research

Vaginitis.

American family physician, 2011

8
Research

Management of vaginitis.

American family physician, 2004

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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