TDM Examination sample case D
Get familiar with the multiple-choice and short-menu question types you will see on the TDM Examination.
A 57-year-old woman presents to your clinic with persistent dysuria with no frequency or urgency. She has dyspareunia and perineal burning with itching. There has been no discharge or bleeding. She had dysuria 10 weeks ago, for which she received antibiotics, but her symptoms did not resolve. Her medical history is otherwise unremarkable, and she has not had a menstrual period in 2 years. She takes no medications. Genital examination reveals a prominent urethral meatus, vulvovaginal erythema, and no skin lesions. The results of a cervical culture are normal. Recent abdominal and pelvic ultrasonogram findings were normal.
The patient does not want a prescription at this time. Which one of the following is the most appropriate first-line therapy? Select 1.
After 6 weeks, the patient returns to your clinic as her symptoms have improved but have not resolved. She requests medication. Which one of the following pharmacologic treatments is most appropriate for this patient? Select 1 or select “None” if none is indicated.
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This presentation is consistent with genitourinary syndrome of menopause, where low estrogen causes vulvovaginal and periurethral atrophy. This can cause dysuria without frequency or urgency; dyspareunia; burning, and/or itching; and no discharge. Physical examination can reveal a prominent urethral meatus and vulvovaginal erythema, and normal results of a cervical culture would be expected. Vaginal moisturizers are an appropriate first-line therapy because they improve hydration and elasticity of atrophic tissue and can reduce irritation-related urinary and sexual symptoms. Drinking 8 cups of water daily may dilute urine but does not address atrophy and can worsen nocturia in some patients. Cranberry juice targets bacterial adherence in recurrent urinary tract infection; this is less likely given the patient’s persistent symptoms despite antibiotics and lack of urinary urgency, frequency, or both. Pelvic floor physiotherapy is more helpful for pelvic pain syndromes, urinary incontinence, and pelvic organ prolapse; it does not directly treat atrophic mucosa. Cognitive behavioural therapy may help the patient cope with chronic pain, but it does not correct the underlying mucosal fragility. Vaginal probiotics are aimed at altering vaginal flora and are not an established first-line therapy for atrophic symptoms without infectious features.
Bachmann GA, Pinkerton JV. Genitourinary syndrome of menopause: Clinical manifestations and diagnosis of vulvovaginal symptoms. UpToDate. Updated March 27, 2026. Accessed May 8, 2026.
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Partial improvement with moisturizers supports an atrophic process that has not fully responded to nonhormonal therapy, so local estrogen is appropriate because it treats the underlying hypoestrogenic changes, restoring vaginal and periurethral epithelium and improving the symptoms. Betamethasone is used for inflammatory dermatoses (often with visible skin changes) and would be inappropriate in a patient with no lesions and normal findings on examination aside from erythema. Clotrimazole treats vulvovaginal candidiasis, which typically includes discharge and characteristic findings; the normal findings of the vaginal examination and culture make this unlikely. Oxybutynin targets overactive bladder with urgency and frequency, which is not present in this scenario. Progesterone does not treat genitourinary syndrome of menopause and would not address local atrophy. Ciprofloxacin targets bacterial urinary tract infection, but persistent symptoms despite prior antibiotics and absence of typical cystitis features argue against ongoing infection. Escitalopram is for mood disorders, anxiety disorders, or both, and would not treat the local atrophic cause of the patient’s symptoms. “None” is incorrect in this setting because treatment is indicated.
Bachmann GA, Pinkerton JV. Genitourinary syndrome of menopause: Clinical manifestations and diagnosis of vulvovaginal symptoms. UpToDate. Updated March 27, 2026. Accessed May 8, 2026.