Vulvovaginal candidiasis and bacterial vaginosis — Rapid

Synopsis

Diagnose and manage candidiasis and bacterial vaginosis accurately, including pregnancy, recurrence, non-albicans yeast, medicine safety and appropriate avoidance of unnecessary partner treatment.

Candida commonly colonises the vagina without disease; treat compatible symptoms and signs, not an incidental positive culture in an asymptomatic person.
Vulvovaginal candidiasis usually causes pruritus, soreness, superficial dyspareunia, erythema or fissuring; discharge may be thick but is typically not offensive and pH generally remains at or below 4.5.
Bacterial vaginosis reflects anaerobic dysbiosis rather than tissue invasion and usually causes thin homogeneous malodorous discharge, pH above 4.5 and little vulval inflammation.
Diagnose bacterial vaginosis with at least three Amsel features or validated Gram-stain or molecular criteria; neither odour nor pH alone is sufficiently specific.
Uncomplicated candidiasis can be treated with a single intravaginal clotrimazole 500 mg pessary or oral fluconazole 150 mg once when suitable; pregnancy requires a topical azole approach rather than oral fluconazole.
Symptomatic bacterial vaginosis can be treated with oral metronidazole 400 mg twice daily for five to seven days; intravaginal metronidazole or clindamycin are alternatives selected for tolerability and context.
Routine treatment of an asymptomatic partner is not recommended for either condition; recurrent symptoms require diagnostic confirmation and review of modifiers rather than serial unsupervised single doses.
Recurrent candidiasis means at least four symptomatic episodes in twelve months and warrants microscopy or culture, species identification and a structured induction and maintenance plan.

Key red flags

Lower abdominal pain, fever, cervical excitation or adnexal tenderness requires assessment for pelvic inflammatory disease and other pelvic emergencies.

Pregnancy with pain, bleeding, collapse or shoulder-tip pain requires urgent ectopic-pregnancy assessment regardless of discharge symptoms.

Extensive oedema, ulceration, necrosis, urinary retention or rapidly spreading erythema suggests severe infection or an alternative vulval disorder.

Persistent postcoital, intermenstrual or postmenopausal bleeding should not be attributed to vaginitis without cervical and cancer-focused assessment.

Refractory symptoms in uncontrolled diabetes or significant immunosuppression need examination, culture and specialist-directed care.

Investigation priorities

Vaginal pH and bedside microscopyFirst step

Support rapid differentiation of acidic Candida-associated inflammation from dysbiosis or trichomoniasis.

Management branches

Initial episodeConfirm the dominant syndrome

A stable patient presents with new vulvovaginal symptoms and no major recurrence history.

Document itch, soreness, odour, discharge, pH where available, pelvic symptoms, pregnancy possibility and recent self-treatment.
Examine when symptoms are atypical, severe or persistent, and obtain microscopy or targeted testing rather than relying on discharge colour alone.
Treat a supported uncomplicated syndrome with a suitable topical or oral regimen and give explicit return advice for non-resolution.

Key medicines

Clotrimazole vaginal pessaryInsert 500 mg intravaginally once for uncomplicated vulvovaginal candidiasis; use a longer topical azole course in pregnancy.Confirm the product instructions, avoid forceful applicator use in pregnancy, and review persistent symptoms rather than repeating doses indefinitely.

FluconazoleTake 150 mg orally as a single dose for suitable uncomplicated vulvovaginal candidiasis.Avoid in pregnancy; review hepatic disease, QT risk and interacting medicines, and confirm recurrent disease before prolonged off-label suppression.

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