Danielle R. Steilen-Matias, PA-C

I am going to start this research article with the stories of people who reach out to us for help with the vaginal pain. The reason for starting out with these stories is to show how many women suffer from this problem, and these problems do not have to be dealt with in a cold medical manner. Patients who deal with this pain are brave. Many tell us of the difficulty of going from doctor to doctor, explaining problems that involve their most intimate bodily functions, from painful orgasms to frequent urination and being given numerous prescription pills that chase the symptoms, until finally, they are called “crazy” or “depressed,” and counseling is recommended. If you have taken this journey, or if you are going down this path right now, this article may be helpful for you. Make no mistake, this is not soft information, this article will be filled with the research from leading medical universities and centers in addressing and finding causes and successful treatment to vaginal pain.

No answers after years – chronic and sometimes acute pain from vagina to low back

This is, unfortunately, typical.  A woman will contact our office, she will tell us that after years of examinations and testing, she still has no definitive diagnosis. She will also tell us that she and her doctors “took a chance,” that maybe a hysterectomy would help. The story goes on that she went from doctor to doctor, and each had their own opinion of what the problem was, and each handed her a referral. She will tell us that she lives with daily, chronic pain that will sometimes spike to an acute phase when she simply lifts her leg to walk up a stair or other natural daily movements. Sometimes the pain will be felt throughout her pelvis and into lower spine. A women’s story like this will usually conclude with: “doctors look at me like I’m crazy.”

It started with laxatives to assist with bowel movements, now I am diagnosed with depression.

From one problem to a series of problems is also something we hear about all the time. An email we received describes this problem. The email has been edited for clarity: “For a year I have had debilitating pain. It began after years of having to take laxatives and push to defecate. Pain in rectum sharp, burning, throbbing. Burning in vagina but no infection. I have been to every doctor, MRI, CT, pet scan. Tried vaginal lidocaine and Botox injections only relief for a few hours. Pregabalin and Tramadol. Only takes the edge off. I have no life but pain and bathroom. My urogynecologist has very little to say. I am beyond depressed.”

Is there really nothing that can be done for me?

Here is another story of a woman with 20 plus years of pain: I have had chronic pelvic pain for 20 years. It started with the birth of my first child and was made worse by my second pregnancy almost five years later. During the pregnancy my pubic symphysis separated and it has remained that way.  I have been to one doctor after another, I have had physical therapy, acupuncture, chiropractor adjustments and even went to the psychotherapist. Is there really nothing that can be done for me?

Severity and frequency of genitourinary symptoms in postmenopausal women, treatment for vulvovaginal discomfort.

An August 2023 study in the journal Menopause (1) asked 302 participants (average age 61 years old) about the severity (0 to three grading), frequency (in days per week) and location (vulvar or vaginal) of itch, dryness, pain/soreness, irritation, as well as severity and frequency of pain with penetration, vaginal discharge, urinary incontinence, and urinary urgency. The most commonly reported symptom across all severity categories was vaginal dryness (285/302, 94%), but the one most frequently rated as severe was pain with vaginal penetration (121/302, 40%). Vaginal dryness was the symptom with highest frequency; 53% of participants with that symptom reported experiencing it  more than four days a week.

For vaginal symptoms, 80% of participants (241/302) reported that at least one of these symptoms occurred during or after sex while only 43% (158/302) reported that at least one vulvar symptom occurred during or after sex. Urinary incontinence (202/302, 67%) and urinary frequency (128/302, 43%) were the two most commonly reported urinary issues.

There are many different causes of vaginal pain, including both structural and non-structural

There are many different causes of vaginal pain, including both structural and non-structural. Non-structural vaginal pain may be caused by an inflammation of the vagina, known as vaginitis, which could be due to a bacterial or yeast infection, or a sexually transmitted disease. It can also be caused by vaginismus, which is pain that occurs when anything enters the vagina. Irritation from hygiene or birth control aids, infections, scars from an injury or surgery, or childbirth may also account for vaginal pain.

In addition, chronic, lingering pain felt deep in the vagina, and often accompanied by pain in the lower back, pelvic area, uterus or bladder, may be caused by medical problems such as pelvic inflammatory disease; endometriosis; a pelvic tumor; bowel or bladder disease, such as interstitial cystitis; scar tissue; or ovarian cysts.

It can disrupt work, sports, marriages, childbearing, household duties with a constant awareness of pain or pressure that begins to rule a person’s life. Just finding a comfortable position can be difficult as any adjustment may put pressure on different areas and cause a different type of pain.

It is interesting to hear the diagnoses people have been given for their conditions. One particularly memorable patient was very happy that someone had finally given her a diagnosis for her pain: vulvodynia. She was crushed when she was told that this meant nothing more than vaginal pain. Vulva means vaginal and dynia means pain. All the doctor did was tell her something she already knew. She had vaginal pain.

The Vagus Nerve

We all have two vagus nerves. One that travels from the head down the body on our right side, and one that travels down our bodies on the left side. The vagus nerve has a critical role in keeping body functions in balance. It helps diverse functions relating to digestion, respiration, blood pressure, and heart rate control. Its profound role is illustrated by abnormalities in it that can lead to far-reaching consequences including gastroesophageal reflux disease, heart failure, failure of respiratory control, gastroparesis, vasovagal syncope, and chronic pain. You can learn more about vagal nerve function in our article Vagus nerve compression in the neck: Symptoms and treatments.

How then does a compressed nerve in the neck cause vaginal problems?

In part the vagus nerve can cause urinary incontinence as described in our article Cervical spine problems, Vagus nerve compression, urinary incontinence. That same article also discusses the connection between vagus nerve and renal failure.

Here is a story from someone looking for help. Their email has been edited for clarity.

I am 35 years old. I have three children. My third child is less than a year old. I have been having abdomen pain since the birth of my second child who is now three years old. I get pain in my upper abdomen after a bowel movement. It mostly goes away, but not always. Sometimes this pain generates headaches. Recently it has been going on all day and especially when I wake up in the morning. I also get this pain when I finish a sports activity which causes the sensation of needing a bowel movement, which in of itself, the bowel movement, causes pain.

My gastroenterologist ordered blood work, MRI and colonoscopy all of which came back normal. I was normal. It was my physical therapist, for mild prolapse of the vaginal wall post natal, who suggested some type of vagus nerve problem. Then I went to an Osteopath, who worked on my spine and this and it seemed to work. The osteopath seems to be the only therapy that has helped.

If vaginal pain lingers and no known source is found, injured, loose or weak ligaments may be the cause

Doctors at the University of Hannover, in Munich have published findings in the journal Current Opinion in Urology (2) that suggests that surgery may represent a possible cure chronic pelvic pain, bladder and bowel dysfunction. The secret they say are the pelvic ligaments.

The purpose of their study was to critically analyze the relationship between symptoms of abnormal emptying of the bladder, urgency, pelvic pain, anorectal dysfunction (hemorrhoids, tears, fistulas, or abscesses) and pelvic organ prolapse (POP – the bladder drops and presses on the vaginal walls) and to present evidence in order to show how many of the above mentioned symptoms can be cured or substantially improved by repair of specific pelvic ligaments.

In their study the German team provided evidence to show how often these dysfunctions occur and how they can be cured in 42-94% by appropriate pelvic floor surgery in the longer term, up to 2 years. The researchers concluded that women bothered by these symptoms should be advised for possibility of cure by pelvic floor ligament repair surgery.

In April 2021, doctors writing in the International Urogynecology Journal (3) evaluated whether nocturia (frequent urination at night) and coexisting pelvic floor symptoms in women with pelvic organ prolapse (POP) can be improved by ligamentous fixation (surgery to repair or support ligaments)  of apical vaginal prolapse to the sacrospinous ligament.

In this study, 277 patients completed a Pelvic Floor Disorder Inventory (PFDI) questionnaire. The doctors found the occurrence rates of “moderate” or “quite a bit” of nocturia was significantly reduced after surgery (48.7% at baseline vs. 19.5% after 24 months). Prevalence rates of co-existing over- and underactive bladder, fecal incontinence, defecation disorders and pain symptoms were also significantly reduced postoperatively. The study concludes: “Nocturia can be associated with symptomatic pelvic organ prolapse (POP), with improvements seen following vaginal ligamentous prolapse repair. We caution providers, however, when advising patients of the possible resolution of nocturia following pelvic organ prolapse (POP) reconstruction, that all other traditional etiologies of nocturia must first be ruled out. ”

Our thoughts: The study demonstrates that repairing ligaments can alleviate the above mentioned symptoms. Our methods are non-surgical. Secondly, the warning that other causes of nocturia must be explored as well. For us, one problem is the vagus nerve dysfunction.

An October 2021 study in the International Urogynecology Journal (4) found “symptoms of voiding dysfunction are frequent in female patients with pelvic organ prolapse (POP) and can significantly improve after vaginal mesh-augmented prolapse repair (to reinforce that vaginal walls) even for posterior and minor defects. Before counseling patients to undergo POP surgery because of their obstructive symptoms, other causes of voiding dysfunction must first have been ruled out.”

Repair of the primary abnormality of uterosacral ligaments laxity

In February 2022, researchers presented evidence to support their hypothesis that vulvodynia is a neuroinflammatory pain syndrome originating in the pelvic visceral nerve plexuses caused by the failure of weakened uterosacral ligaments to support the pelvic visceral nerve plexuses (a network of nerves that supply the muscles, glands, and organs of the pelvis.) Writing in the Archives of Gynecology and Obstetrics (5) the authors continue: “Repair of the primary abnormality of uterosacral ligaments laxity, responsible for mechanical stimulation of the pelvic sensory plexus, may lead to resolution of the pain syndrome.”

Laxity in ligaments (instability in the vaginal region caused by ligament damage and degeneration) and/or vaginal membrane due to damaged connective tissue may prevent the normal opening and closure mechanism of urethra and anus, because muscles need finite lengths to contract properly. Hypermobility of the vaginal apex (the uterus and cervix in women who have not undergone a hysterectomy, and the uterus and vaginal wall in women who have), can irritate the pelvic plexus (the nerve branches of the pelvic region) causing chronic pelvic pain. In consequence, dysfunctions as abnormal emptying of the bladder, urgency, pelvic pain, fecal incontinence and obstructed defecation can occur in women with different degrees of POP.

At Caring Medical, we frequently find patients with chronic pelvic pain have underlying and unresolved ligament laxity. As opposed to surgery, we off non-surgical repair of the pelvic ligaments.

Vaginal pain that has not responded to surgery or conservative treatments may become classified as chronic and with unknown origin. If an underlying cause cannot be found, patients are often advised to continue with anti-inflammatory medications or steroid shots to control their pain. While these treatments may help temporarily, cortisone shots and NSAIDs can both result in long term loss of function.

Sometimes physical therapy is recommended to try and build the muscles up through the pelvic floor, groin and low back, which often only partially help the issue.

When chronic vaginal pain cannot be resolved, ligament laxity may be the culprit. A problem of Ehlers-Danlos Syndrome

In some patients, ligament laxity is caused by injury as described above. In other patients there are problems of ligament laxity caused by hypermobile Ehlers-Danlos Syndrome. If you have been diagnosed with Hypermobile Ehlers-Danlos Syndrome you will likely not need to be told of the complexity of treatment. You yourself are probably a very complex case. As people with Hypermobile Ehlers-Danlos Syndrome also suffer from issues of self-doubt because some of their doctors don’t believe them and they suffer from clinical-level depression.

Hypermobile Ehlers-Danlos Syndrome, in simplest terms, means you are “double-jointed.” However, this ability to rotate joint seemingly beyond normal range also means that the connective tissue that holds the pelvic floor and vagina in placer are also “hypermobile” they stretch too far and are unable to “hold you in place.” Ehlers-Danlos Syndrome is a hereditary defect in the collagen that builds proteins. Proteins build ligaments. A defect in the protein means there ids a defect in the ligament that makes the ligament weaker. Please see our article Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders Injection Treatments.

Here is an email we received that will help put a human face on this. The email has been edited for clarity.

“I have Hypermobile Ehlers-Danlos Syndrome and Mast cell activation syndrome (an autoimmune response). I am 30 years old and I have rectal, bowel, vaginal and bladder prolapses as well. I delivered all my children by natural deliveries. I had a coccyx injury 6 months ago too, which worsened everything. I have tried gynecology physical therapy on and off for a few years, but find it actually makes my vaginal prolapse worse.”

Ligament laxity can occur after a sudden injury to the low back or pelvic floor or after childbirth.

Ligament laxity can occur after a sudden injury to the low back or pelvic floor or after childbirth. During pregnancy, a hormone called relaxin is released inside the body to help relax the ligaments along the pelvic floor to better allow the baby to pass through the birth canal. It is not unheard of for women to be left with chronic vaginal or pelvic floor pain after childbirth that is related to loose ligaments.

In many cases, the iliolumbar ligament and/or sacrococcygeal ligament in the low back is involved. These weak ligaments can refer pain around to the groin or vagina and cause chronic agony. Thus, a better approach to chronic vaginal pain is to stimulate the repair of these ligaments with Prolotherapy. Once the weakened tissues are identified and strengthened, chronic pain in the vagina usually abates.

Numerous ligaments surround the pelvis and help to keep it stabilized. When these ligaments become weak, they are unable to maintain pelvic stability and can cause pain. They may also be tender to palpation (touch). Patients with chronic pelvic pain are frequently tender over the pubic symphysis or sacroiliac joints, often signifying weakened ligament tissue.

For chronic vaginal pain due to ligament or tendon weakness, Prolotherapy is an effective treatment option. Prolotherapy is a regeneration injection therapy (RIT) that stimulates the body to repair injured tissues and painful areas. Thus, the pain radiating into the vagina and other pelvic floor areas can be eliminated.

Please see our related articles:

• Pelvic Floor Dysfunction – New research is not only suggesting a high risk of Pelvic Floor Dysfunction in women who give childbirth and suffer from obesity, but also in high-level female athletes.
• Pelvic and Spinal instability from the facet joint – Doctors have released new research in which they investigated the relation between the structures of the low back, sacrum, and pelvis and how degenerating facet joints influenced  lower spine instability.
• Symphysis Pubis Dysfunction Treatment – Recent research confirms what we hear from patients following childbirth who suffer from Pelvic Girdle Pain (PGP) or Symphysis Pubis

Citing results of the Pelvic Floor Repair Systems for Prolapse Repair (PROPEL) study, urologists in Germany published their 2024 study (6) citing outcomes of vaginal ligament repair. “Ligamentous vaginal repair of pelvic organ prolapse enables symptom cure in high percentages for urinary urge incontinence (up to 82%), nocturia (up to 92%), obstructive micturition (blocked urination) (up to 87%), fecal incontinence (58-72%), obstructive defecation (71-84%), and pain (53-90%), if caused by pelvic organ prolapse.

Injections

In December 2023, Italian doctors published (7) their observations that botulinum toxin injection can be effective in improving vulvar and vaginal dyspareunia (painful intercourse), vaginismus (vaginal tightening spasms), and chronic pelvic pain. No irreversible side effects were detected. Major side effects reported were transient urinary or fecal incontinence, constipation and rectal pain.

We can help chronic vaginal and pelvic floor pain

In our office, we have success treating a lot of pain in the pelvic, groin, and vaginal region in women who have chronic pain. Our Comprehensive Prolotherapy approach typically requires three to six treatments, given approximately one month apart. For an athlete or new mom, this type of treatment is ideal because it does not require needing to take medications and allows the woman to remain active, and encourages motion and exercise, between treatments.

Prolotherapy of the iliolumbar ligament can be curative for chronic groin, testicular, vaginal pain, and symptoms associated with pelvic floor dysfunction.

Prolotherapy to the pelvis involves a dextrose injection treatment to any of the numerous ligaments that may be weak and causing the pelvic instability. This treatment initiates a mild inflammatory response in the treated pelvic area. D-glucose (also called dextrose) is the normal sugar in the body, and when injected activates the immune system.  The body’s normal healing inflammatory reaction boosts the blood flow to the area and attracts immune cells to the weakened or injured ligaments being treated. These cells will cause regeneration and strengthening of the injured areas. Once the ligaments are strengthened, the pelvis becomes stabilized. Referral pain will stop, contracted muscles will relax, and the chronic pelvic pain will abate.

References

1 Liedl B, Goeschen K, Durner L. Current treatment of pelvic organ prolapse correlated with chronic pelvic pain, bladder and bowel dysfunction. Current opinion in urology. 2017 May 1;27(3):274-81. [Google Scholar]
2 Himmler M, Rakhimbayeva A, Sutherland SE, Roovers JP, Yassouridis A, Liedl B. The impact of sacrospinous ligament fixation on pre-existing nocturia and co-existing pelvic floor dysfunction symptoms. International urogynecology journal. 2021 Apr;32:919-28. [Google Scholar]
3 Maren H, Aidana R, Sutherland SE, Jan-Paul R, Alexander Y, Bernhard L. The impact of sacrospinous ligament fixation on pre-existing nocturia and co-existing pelvic floor dysfunction symptoms. International Urogynecology Journal. 2021 Apr 1;32(4):919-28. [Google Scholar]
4 Bornstein J, Palzur E, Swash M, Petros P. Vulvodynia: a neuroinflammatory pain syndrome originating in pelvic visceral nerve plexuses due to mechanical factors. Archives of Gynecology and Obstetrics. 2022 Nov;306(5):1411-5. [Google Scholar]
5 Liedl B, Barba M, Wenk M. Pelvic floor reconstruction-update 2024: prolapse-associated symptoms and their treatment. Urologie (Heidelberg, Germany). 2023 Dec 28;63(1):43-50. [Google Scholar]
6 Parenti M, Degliuomini RS, Cosmi E, Vitagliano A, Fasola E, Origoni M, Salvatore S, Buzzaccarini G. Botulinum toxin injection in vulva and vagina. Evidence from a literature systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2023 Dec 1;291:178-89. [Google Scholar]