{ "schema_version": 1, "kind": "condition", "id": "vaginismus", "name": "Vaginismus (Genito-Pelvic Pain/Penetration Disorder)", "category": "chronic", "sources": "Merck Manual Professional Edition: Genito-Pelvic Pain/Penetration Disorder · Amitriptyline 10 mg Film-Coated Tablets SmPC section 4.2 (eMC product 10849), neuropathic pain dosing · Gabapentin DailyMed label, SetID 03031adf-d36b-45ec-944e-dfce5a5de91a, section 2.1", "review_status": "reviewed", "verified_against": "Merck Manual Professional Edition: Genito-Pelvic Pain/Penetration Disorder", "verified_date": "2026-08", "treatments": [ { "id": 1926, "generic": "No drug therapy in primary care (Physiotherapy & Psychosexual Referral)", "line": 1, "is_adjunct": false, "form": null, "strength_mg": null, "adult_dose": "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.", "adult_duration": "Ongoing until penetration is achieved without pain or involuntary spasm; typically weeks to months, often combining approaches", "dose_source": "Merck Manual Professional Edition: Genito-Pelvic Pain/Penetration Disorder", "rationale": "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.", "cautions": [ "Vaginismus is a diagnosis of exclusion - first rule out organic causes of penetration pain: vulvovaginal atrophy, vulvodynia, candidal or other vaginitis, lichen sclerosus, endometriosis, and sequelae of female genital cutting, which are all seen in Egyptian primary care.", "A gentle, fully consented examination helps confirm involuntary muscle spasm and exclude structural pathology, but must never be forced - a forced or painful exam can worsen the fear-pain cycle and damage trust.", "Ask sensitively about a history of sexual trauma or abuse, and refer early for psychosexual therapy where present, rather than proceeding with dilators alone.", "In a premarital-clinic context, address the couple's expectations and involve the partner in education where the patient consents, since fear and relationship dynamics commonly maintain the condition." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "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.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [], "condition_id": "vaginismus" }, { "id": 1928, "generic": "Amitriptyline", "line": 3, "is_adjunct": false, "form": "oral.solid", "strength_mg": 10.0, "adult_dose": "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", "adult_duration": "Allow 2 to 4 weeks at an adequate dose before judging whether it helps; if it does, continue and review regularly", "dose_source": "Amitriptyline 10 mg Film-Coated Tablets SmPC section 4.2 (eMC product 10849), neuropathic pain dosing", "rationale": "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.", "cautions": [ "Do not start it after a recent heart attack, or in anyone with heart block, an arrhythmia or coronary artery insufficiency.", "It must not be combined with a monoamine oxidase inhibitor, and a washout period is needed when switching either way.", "Avoid it in severe liver disease.", "It is sedating and anticholinergic - warn about morning drowsiness, dry mouth, constipation and driving, and give the dose in the evening.", "The pain-relieving effect is separate from any antidepressant effect, and the doses used here are far below antidepressant doses; tell the patient that, so she does not think she is being treated for depression.", "Stop it gradually rather than abruptly." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Not for anyone under 18 years: the SmPC states safety and efficacy have not been established in children and adolescents below that age.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "TRYPTIZOL 10 MG 20 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "KAHIRA", "price_egp": 10.0, "pack_count": 20, "unit_price": 0.5, "strength_mg": 10.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "TRYPTIZOL 10 MG 60 TABS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "KAHIRA", "price_egp": 30.0, "pack_count": 60, "unit_price": 0.5, "strength_mg": 10.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "GRANITYLLIN 25MG/5ML SYP. 120 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "GRAND PHARMA > DELTA GRAND PHARMA", "price_egp": 5.0, "pack_count": null, "unit_price": null, "strength_mg": 25.0, "exact_strength": false, "exact_form": false, "discontinued": false, "also_contains": null }, { "trade_name": "ZINOTRAVAL 25MG/5ML SYP. 120 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "DEBEIKY > PHARMACHEMIC", "price_egp": 10.0, "pack_count": null, "unit_price": null, "strength_mg": 25.0, "exact_strength": false, "exact_form": false, "discontinued": false, "also_contains": null } ], "condition_id": "vaginismus" }, { "id": 1929, "generic": "Gabapentin", "line": 4, "is_adjunct": false, "form": "oral.solid", "strength_mg": 300.0, "adult_dose": "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", "adult_duration": "Titrate over days to weeks and judge the effect at an adequate dose; continue if it helps, reviewed regularly", "dose_source": "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).\"", "rationale": "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.", "cautions": [ "The dose must be reduced in renal impairment, because gabapentin is cleared by the kidneys.", "It causes drowsiness and dizziness, especially while the dose is going up - warn about driving until she knows how it affects her.", "Never stop it abruptly; taper it, since abrupt withdrawal can provoke seizures in anyone with a seizure disorder.", "It can cause severe breathing depression when combined with opioids or other sedatives, or in a patient with existing respiratory disease.", "Stop it and seek help for any widespread rash, facial swelling or systemic reaction - serious hypersensitivity reactions are reported.", "It is being used off-label for this indication; explain that to the patient." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Not applicable - adult women only.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "EZAPENTIN 300MG 10 CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MULTI-APEX", "price_egp": 11.0, "pack_count": 10, "unit_price": 1.1, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "PENTALIPSY 300MG 10 CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SAFE PHARMA", "price_egp": 14.4, "pack_count": 10, "unit_price": 1.44, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "OCTOCONVAL 300 MG 30 CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "OCTOBER PHARMA", "price_egp": 72.0, "pack_count": 30, "unit_price": 2.4, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "NEUROGLOPENTIN 300 MG 30 CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "GLOBAL NAPI PHARMACEUTICALS", "price_egp": 111.0, "pack_count": 30, "unit_price": 3.7, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "SHALGATEN 300MG 30 CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EGPI > MASH PREMIERE", "price_egp": 126.0, "pack_count": 30, "unit_price": 4.2, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "GABALEPSY 300MG 30 CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EL-OBOUR", "price_egp": 135.0, "pack_count": 30, "unit_price": 4.5, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "GABAVERONA 300 MG 30 H.G. CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "AVERROES PHARMA", "price_egp": 126.0, "pack_count": null, "unit_price": null, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "SAJALIPSY 300 MG 30 H.G. CAPS.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SAJA PHARMACEUTICALS", "price_egp": 126.0, "pack_count": null, "unit_price": null, "strength_mg": 300.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "STABLENTIN 6MG/120ML SYRUP", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MEPACO", "price_egp": 21.6, "pack_count": null, "unit_price": null, "strength_mg": 6.0, "exact_strength": false, "exact_form": false, "discontinued": false, "also_contains": null }, { "trade_name": "ADAPTAN 250MG/5ML ORAL SOLUTION 100 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EUROPEAN EGYPTIAN PHARM. IND.", "price_egp": 37.0, "pack_count": null, "unit_price": null, "strength_mg": 250.0, "exact_strength": false, "exact_form": false, "discontinued": false, "also_contains": null } ], "condition_id": "vaginismus" }, { "id": 1927, "generic": "Lidocaine", "line": 2, "is_adjunct": true, "form": "topical", "strength_mg": null, "adult_dose": "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.", "adult_duration": "Short-term, as-needed adjunct only; reassess the need for it as physiotherapy and dilator therapy progress", "dose_source": "Merck Manual Professional Edition: Genito-Pelvic Pain/Penetration Disorder", "rationale": "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.", "cautions": [ "This is an off-label, short-term adjunct with no dedicated dosing guideline for vaginismus specifically - it is not a primary treatment and should not be prescribed on its own.", "Can cause local stinging on application, and numbness that may itself interfere with sensation during dilator use or intercourse - use sparingly.", "Can damage latex condoms - advise an alternative contraceptive/barrier method while in use.", "Do not let this become a way to tolerate penetration through unaddressed pain - used without the physiotherapy/dilator/psychosexual work above, it risks reinforcing the fear-pain cycle rather than resolving it." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Not indicated in children.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "LIDOCAINE 2% GEL. 20 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ALEXANDRIA", "price_egp": 6.75, "pack_count": null, "unit_price": null, "strength_mg": 20000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "XYLOCAINE JELLY 2% 30 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ASPEN PHARMA > PHOENIX GROUP", "price_egp": 30.8, "pack_count": null, "unit_price": null, "strength_mg": 30000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "FARCO-CAINE 5% OINT. 20 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "PHARCO", "price_egp": 4.25, "pack_count": null, "unit_price": null, "strength_mg": 20000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIDOSINE 5% TOPICAL OINT. 20 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "AMRIYA", "price_egp": 4.4, "pack_count": null, "unit_price": null, "strength_mg": 20000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIDOGED 5% TOPICAL GEL 15 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "JEDCO INT. CO. FOR PHARMACEUTICALS", "price_egp": 5.0, "pack_count": null, "unit_price": null, "strength_mg": 15000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "XYLOTOP 4% TOPICAL GEL 20 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SIGMA", "price_egp": 5.0, "pack_count": null, "unit_price": null, "strength_mg": 20000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIGNOCAINE 5% CREAM 20 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EL NILE.", "price_egp": 24.0, "pack_count": null, "unit_price": null, "strength_mg": 20000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "ULTRACAINE 5% GEL 30 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MEMPHIS", "price_egp": 31.0, "pack_count": null, "unit_price": null, "strength_mg": 30000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "vaginismus" } ] }