Vaginismus (Genito-Pelvic Pain/Penetration Disorder)

Educate on vulvovaginal anatomy and the fear-pain-muscle spasm cycle. Refer for pelvic floor physiotherapy (biofeedback, soft-tissue release, graded relaxation of the pelvic floor) and for progressive vaginal dilator therapy (graduated dilator sizes, left in place approximately 10-15 minutes per session). Refer for psychosexual therapy or cognitive-behavioural therapy where fear/anxiety about penetration or a history of sexual trauma is prominent. - Ongoing until penetration is achieved without pain or involuntary spasm; typically weeks to months, often combining approaches

Not applicable to prepubertal children. In adolescents presenting with this pattern, refer to a gynaecologist with adolescent experience rather than managing in primary care alone.

Merck Manual Professional Edition: Genito-Pelvic Pain/Penetration Disorder

Pelvic floor physiotherapy, graduated dilator therapy, and psychosexual/CBT referral are the mainstay of management and address the underlying involuntary pelvic floor spasm and fear-avoidance cycle directly; no medication reverses this mechanism, and ACOG does not rank one non-drug approach above the others - the right mix depends on presentation.

Apply a thin layer of 2% or 5% lidocaine gel/ointment to the vaginal introitus and vulvar vestibule 15-20 minutes before dilator sessions or intercourse, to blunt the entry pain that triggers protective muscle spasm. Use short-term only, and always alongside - never instead of - pelvic floor physiotherapy and dilator/psychosexual therapy. - Short-term, as-needed adjunct only; reassess the need for it as physiotherapy and dilator therapy progress

Not indicated in children.

Merck Manual Professional Edition: Genito-Pelvic Pain/Penetration Disorder

No guideline reviewed publishes a specific dosing regimen for topical lidocaine in vaginismus; the source used states only that a topical lidocaine gel can be applied before activities that cause discomfort and should be used for a short time only, and describes medication as adjunct - never first-line - throughout. No numeric dose is given here, because no source supports one.

Start 10 mg to 25 mg once daily in the evening, increasing by 10 mg to 25 mg every 3 to 7 days as tolerated; the usual effective range is 25 mg to 75 mg daily in the evening - Allow 2 to 4 weeks at an adequate dose before judging whether it helps; if it does, continue and review regularly

Amitriptyline 10 mg Film-Coated Tablets SmPC section 4.2 (eMC product 10849), neuropathic pain dosing

Where the pain has a burning, neuropathic quality or persistent pelvic floor spasm, a low nightly dose of amitriptyline is the one systemic option a GP can reasonably start and titrate. It is an add-on to physiotherapy and psychosexual work, never a substitute for them.

300 mg on day 1, 300 mg twice daily on day 2, then 300 mg three times daily on day 3; titrate further as needed for pain relief up to 1800 mg a day in three divided doses - Titrate over days to weeks and judge the effect at an adequate dose; continue if it helps, reviewed regularly

Not applicable - adult women only.

Gabapentin DailyMed label, SetID 03031adf-d36b-45ec-944e-dfce5a5de91a, section 2.1 - verbatim: "In adults with postherpetic neuralgia, gabapentin may be initiated on Day 1 as a single 300 mg dose, on Day 2 as 600 mg/day (300 mg two times a day), and on Day 3 as 900 mg/day (300 mg three times a day). The dose can subsequently be titrated up as needed for pain relief to a dose of 1800 mg/day (600 mg three times a day)."

The second systemic option for the same job as amitriptyline, chosen when a tricyclic is unsuitable - cardiac disease, marked anticholinergic intolerance, or an inadequate response. The dose figures come from the label's neuropathic-pain (postherpetic neuralgia) schedule, because no vaginismus-specific source publishes a titration. Like amitriptyline it is an add-on to physiotherapy and psychosexual therapy.