TEALE FENNING

Nick Raine-Fenning

One of the Gynaecology short answers was about a womna with unspecificed dyspareunia following childbirth, albeit 6 months later. It read something like ...

A 29-year old woman complains of dyspareunia 6 months after the birth of her first child.

 What points from her delivery and puerperium may help you identify the cause? (8 marks)

 What other causes are there? (5 marks)

 What would you look for on examination? (7 marks)

Seems like a pretty straightforward question especially as the last part of the question means you only need to talk about history in the first part!

Post your suggested answers.
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Nick Raine-Fenning · Posted: Tue Dec 05, 2006 5:53 pm Post subject:

Now this question has tested me more than any of the others Embarassed

I am not sure why but I think it is written poorly Rolling Eyes

The question essentially calls for assessment of the patient without any investigations - an old 'clinical features' question if you like.

This is straightforward but they then restrict the first section to questions relating to delivery and the puerperium. What about pre-exisiting disease? She is 6 months postpartum so there is every chance this is pre-exisiting problem or a new one unrelated to childbirth. The question does not really allow you to explore this as it is written. Evil or Very Mad

Either I am missing the point or the answers include facts unrelated to "delivery and the puerperium" - the question is a bad one if these other issues cannot be considered.

Nick Raine-Fenning · Posted: Tue Dec 05, 2006 5:55 pm Post subject:

As regards the differential diagnosis

Gynaecological

endometriosis
pelvic inflammatory disease
atrophy
vulvodynia
ovarian cyst
fibroids
adenomyosis

General

allergic / contact dermatitis
lichen sclerosis
UTI, interstitial cystitis
inflammatory bowel

Psychosocial

depression
abuse

Helena Lim · Posted: Wed Dec 06, 2006 1:04 am Post subject:

Would you consider these differentials?

Vaginismus
Vestibulitis
Breast feeding associated atrophy
granulation/fibrous tissues
tight interoitus following overzealous suturing of perineum

Helena Lim
Laughing

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Helena Lim
MD (UKM), MMeds (Malaysia), MRCOG
South-East Asian Administrator for Teale Fenning Medical Education

Nick Raine-Fenning · Posted: Wed Dec 06, 2006 9:23 am Post subject:

I think they are the key ones for sure but in this order:

Breast feeding associated atrophy
Granulation / fibrous tissue
Tight interoitus following over zealous suturing of perineum
de novo disease (infection, endometriosis, etc)
Vestibulitis
Vaginismus

and lastly ... psychological causes including depression, call for help etc. This is important to mention and will score marks but should be held in reserve so the examiner / marker knows you are aware of this but that you do not think it is the primary cause in the majority!

It's an old Teale Fenning rule that works - put the sinister and pyschological causes at the end as an important thing to exclude which affects some patients presenting in this way (whatever way that may be).

Examples include:

vaginal discharge in a child - cancer, abuse
hirsutism - adrenal / ovarian cancer
abdominal pain in pregnancy - domestic violence

However, as far as the differentials are concerned the second part of this question probably includes the causes unrelated to childbirth as all the ones you mention would be addressed in the first section.

This is a tough question as a result as it is hard to know where to put things - something many candidates mentioned as a big issue.