A 32-year-old woman telephones the office due to continued vaginal discharge and vulvar pruritus. She first noticed the presence of a white, malodorous vaginal discharge a week ago. The patient began using an over-the-counter antifungal cream at that time. A few times last year she had similar symptoms that resolved with the same medication. The patient was diagnosed with type 1 diabetes mellitus 20 years ago. She has had no surgeries. The patient has no medication allergies and does not use tobacco, alcohol, or illicit drugs. Family history is noncontributory. She is sexually active and uses a levonorgestrel-releasing intrauterine device for contraception. The patient is concerned about the ongoing symptoms and asks for a recommendation of a more effective treatment. Which of the following is the most appropriate response?

Question

A 32-year-old woman telephones the office due to continued vaginal discharge and vulvar pruritus.  She first noticed the presence of a white, malodorous vaginal discharge a week ago.  The patient began using an over-the-counter antifungal cream at that time.  A few times last year she had similar symptoms that resolved with the same medication.  The patient was diagnosed with type 1 diabetes mellitus 20 years ago.  She has had no surgeries.  The patient has no medication allergies and does not use tobacco, alcohol, or illicit drugs.  Family history is noncontributory.  She is sexually active and uses a levonorgestrel-releasing intrauterine device for contraception.  The patient is concerned about the ongoing symptoms and asks for a recommendation of a more effective treatment.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c14a_8754_8f63_972a6215c7e5_MD0005_00 The typical features of vaginitis (ie, discharge, pruritus, odor) are common and nonspecific, and often lead to incorrect self-diagnosis and over-the-counter treatment. Etiologies include infections of the vulva, vagina, and cervix. Noninfectious causes are chemicals, irritants, hormonal disorders, and (rarely) some systemic disorders. The most common infections are bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. History alone is not reliable and should be confirmed in the office by a pelvic examination and wet mount microscopy or nucleic acid amplification testing to avoid misdiagnosis and inappropriate treatment. (Choice A) A detailed sexual history can provide further evidence of a specific infection, but laboratory evidence is required for appropriate therapy. (Choice B) Prescribing fluconazole is inappropriate in the absence of a specific diagnosis. (Choice C) Intrauterine devices do not increase the risk of vaginitis, and treatment of pelvic infections does not require their removal. (Choice D) Tight blood sugar control is important to prevent recurrences of vulvovaginal candidiasis; however, it does not replace microscopy for diagnostic confirmation. Educational objective: Clinical features of vaginitis are common, nonspecific, and can lead to incorrect self-diagnosis. The diagnosis should always be confirmed by wet mount microscopy or nucleic acid amplification testing to avoid inappropriate treatment. References: Vaginitis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/21084788)

A 32-Year-Old Woman Telephones the Office Due to Continued Vaginal