Vulvovaginal Pain

Terms Related to Vulvovaginal Pain

• Vulvodynia: persistent pain in the vulva with no specific identifiable cause
• Vestibulodynia: pain near the entrance to the vagina
• Vaginismus: involuntary contraction of the muscles around the vagina during an attempt at penetration
• Dyspareunia: Pain During Sexual Intercourse

What is vulvovaginal pain?

Vulvovaginal pain refers to pain felt in the vulva or vagina, which may be constant or triggered by contact such as sexual intercourse, inserting a tampon, or wearing tight clothing. Treatment depends on the cause and may include physical therapy for the pelvic floor—the muscles located at the base of the pelvis.

You experience pain during intercourse, a persistent burning sensation, or discomfort from the mere touch of your underwear. Perhaps you’ve consulted several healthcare professionals without getting clear answers. You’re not alone: about 10 to 20 percent of women in the United States experience recurring or persistent pain during sex.¹

Pelvic physical therapy can reduce pain and improve your sex life, particularly in cases of induced vestibulodynia—pain triggered by contact with the vaginal opening. Your pain is real. An evaluation will help determine the right treatment for you.

A study compared 56 women with induced vestibulodynia to 56 women without symptoms. On average, the pelvic floor muscles were more tense at rest and weaker in the women experiencing pain. Their coordination and endurance were also reduced.²

• Chronic pain, which lasts more than three months, may be accompanied by changes in how the nervous system processes signals³
• Pelvic physical therapy is one of the treatments recommended from the outset for^{vulvodynia4, 5}

Vulvovaginal pain refers to all pain felt in the vulva and vagina. This pain can be constant or appear during specific contacts, such as sexual intercourse, tampon insertion, or even wearing tight clothing.

The vulva refers to the external part of the female genitals, while the vagina is the internal canal. Pain can affect either or both of these regions.

Prevalence estimates vary depending on the population and the definition used. One review reports that vulvodynia affects approximately 8 to 10 percent of women.⁵ In an online survey conducted in Portugal among 1,229 adult women, 16% reported having experienced it at some point in their lives; this survey required symptoms to have lasted at least six months.⁶ Some women consult several healthcare professionals before receiving a diagnosis.

What are the different forms of vulvovaginal pain?

Vulvovaginal pain may be caused by vulvodynia—including vestibulodynia—or may accompany vaginismus and other medical conditions. Dyspareunia refers to pain during sexual intercourse, without specifying the cause. Several of these conditions may occur simultaneously.

Classification by Location

Vulvodynia is pain in the vulva that has persisted for at least three months, with no other identifiable cause.⁷ It can be generalized (affecting the entire vulvar region) or localized.

Vestibulodynia is pain specifically localized to the vestibule, the entrance to the vagina. It is the most common form of induced vulvar pain.⁸

Clitoridynia is pain localized to the clitoris; it is less common but just as debilitating.

Classification Based on the Onset of Pain

Pain is considered primary when it occurs during the very first attempts at penetration or tampon insertion.

Secondary pain appears after a pain-free period, sometimes following a trigger event such as childbirth, an infection, or a hormonal change.

Classification by Trigger

Provoked pain is triggered by contact, such as sexual intercourse, tampon insertion, a gynecological exam, or even clothing friction.

Spontaneous pain is present without an identifiable trigger.

Related Issues

Vaginismus is characterized by an involuntary contraction of the pelvic floor muscles during an attempt at penetration, making penetration difficult or impossible.⁹

Dyspareunia refers to recurrent or persistent pain during sexual intercourse. The pain may be felt at the entrance to the vagina or deeper inside.

What are the symptoms of vulvovaginal pain?

Vulvovaginal pain can cause a burning sensation, itching, a throbbing pain, or a tearing sensation. The pain may be constant or occur during activities such as sexual intercourse, inserting a tampon, or wearing tight clothing.

Types of Sensations Experienced

• Burning: the most frequently reported symptom
• Itching: sometimes mistaken for an infection
• Throbbing pain: a "stabbing" sensation
• Tearing sensation: as if the tissues are tearing
• Warmth or persistent irritation

Frequent triggers

Women often report that their pain appears or worsens during:

• Sexual intercourse (penetration)
• Inserting a tampon or a menstrual cup
• Gynecological exam
• Friction from underwear or tight clothing
• Prolonged sitting
• Cycling or horseback riding

Aggravating factors

Certain factors can worsen symptoms:

• Stress and anxiety
• Recurrent infections, including yeast infections (known as fungal infections) and urinary tract infections
• Certain soaps or feminine hygiene products
• Fatigue or lack of sleep

What are the possible causes of vulvovaginal pain?

Vulvovaginal pain can result from an infection, a skin condition, hormonal changes, an injury, or a nerve or muscle problem. In cases of vulvodynia, no single specific cause alone explains the pain; several factors may contribute to its onset or persistence.

Real pain, even without visible injury

Your pain deserves to be taken seriously, even if the exam doesn't show any injury. Stress, emotions, or relationships can influence real pain; that doesn't mean you're making it up.

With this type of pain, the discomfort can be very real even when no tissue damage is found upon examination.¹⁰

Muscle changes may accompany vestibulodynia. In the study of 56 women with pain, the measurements did not make it possible to determine whether these changes preceded the pain or appeared afterward.

The Role of the Pelvic Floor

The pelvic floor is a group of muscles located at the bottom of the pelvis. These muscles can become hypertonic—that is, too tense—over a long period of time.

These muscles must be able to contract and then relax. Difficulty relaxing them, tenderness to the touch, or a lack of coordination may contribute to the symptoms. The evaluation also assesses muscle strength, since increased muscle tone and weakness can occur simultaneously.

Research is also being conducted on nerves and inflammation. A small tissue study found more nerve fibers and certain immune cells in eight women with pain than in four women without that pain; experiments testing the inflammatory mechanism were conducted in animals.¹¹ A review also describes increased nerve fiber growth in certain tissues of women with vestibulodynia or endometriosis, a condition in which tissue similar to that found inside the uterus grows elsewhere. The precise role of these changes in pain remains to be determined.¹²

Another study separately assessed weakness, coordination, and tenderness in the pelvic muscles of 108 women with lower back or pelvic pain. The factors examined did not predict muscle weakness. Tenderness and strength must therefore be assessed separately.¹³

Contributing factors

Several factors are associated with pain or may influence symptoms:

The vicious cycle

Pain can lead to a protective muscle contraction; difficulty relaxing the muscles can, in turn, perpetuate the discomfort. This cycle may occur in some people, but it does not explain all cases of vulvovaginal pain.

Several mechanisms can contribute to the persistence of pain, even after an initial injury has healed. Acute pain and persistent pain are distinguished primarily by their duration; persistence alone does not prove that a medical cause has disappeared.

In the study of 108 women with lower back or pelvic pain, a high score on the central sensitization questionnaire was associated with pain in the pelvic muscles upon pressure. This observation links these symptoms; it does not establish a diagnosis of central sensitization and does not specifically describe women with vulvovaginal pain.¹³

Understanding Your Options for Care

Your pain is real, even if its exact cause has not been identified. Treatments can reduce your symptoms and help you resume your activities.

So-called nociplastic mechanisms, which alter how the nervous system processes signals, may contribute to certain forms of vulvodynia. They are also being studied in other chronic pain conditions, such as irritable bowel syndrome—a digestive disorder—or endometriosis. They may coexist with tissue disease or nerve damage.¹⁰

How is vulvovaginal pain diagnosed?

The diagnosis of vulvovaginal pain is based on a detailed questionnaire and an examination of the painful area. The healthcare professional will assess the exact location of the pain, any triggers, and the condition of your pelvic muscles. Medical tests may be performed to rule out an infection or other condition before a diagnosis of vulvodynia is made.

What your healthcare professional will assess

During your appointment, you will be asked questions about:

• The exact location of your pain
• How long you've had the pain
• What triggers or worsens the pain
• Your medical and gynecological history, including past health issues and treatments
• The impact on your daily and intimate life

Physical examination

The exam is always conducted with your consent and at your own pace. It may include:

• An external assessment of the vulva
• A cotton swab test to pinpoint the exact painful areas
• An assessment of pelvic floor tension

You may stop the exam at any time if you wish.

Possible additional tests

Your doctor may order tests to look for other causes:

• Collection of vaginal secretions, which are analyzed in a laboratory to check for an infection
• Tests for sexually transmitted infections
• Sometimes a biopsy—the removal of a small piece of tissue for analysis—is performed if a lesion needs to be examined

When to seek physiotherapy for vulvovaginal pain?

Persistent vulvar or vaginal pain that affects intimate relationships or limits daily activities is a reason to seek physical therapy. You can consult directly with a physical therapist who specializes in perineal rehabilitation and the care of pelvic muscles and functions. A medical evaluation is still important to rule out an infection, a skin condition, or another underlying cause.

Consult if you experience:

• Pain during sexual intercourse
• Pain When Inserting a Tampon
• Persistent vulvar discomfort
• Chronic burning sensation
• Pain that limits your daily activities

You can ask for help right now

• You don't have to wait until the pain gets really bad to ask for help.
• You can schedule a physical therapy appointment while the medical evaluation is being arranged.
• A physical therapist can refer you to the necessary medical care; if you have a sign of an emergency, seek that care immediately.

Good to Know

A physical therapist can refer you to the appropriate specialist if your symptoms require further evaluation. You should also see a doctor if you experience recurring or persistent pain, a change in your skin, or a wound, rather than assuming it’s just muscle strain.

When is urgent care needed?

Lower abdominal pain requires urgent medical attention if it is accompanied by any of the following symptoms: difficulty urinating or having a bowel movement, blood in the urine or stool, unusual vaginal discharge or bleeding, pain when urinating or a need to urinate more frequently, a very high fever or a feeling of being hot, cold, or having chills, vomiting with diarrhea, or nausea. A possible or confirmed pregnancy accompanied by this pain also requires urgent medical attention. If you have lower abdominal pain, go to the emergency room if it is severe, getting worse, or hurts when you move or touch the area, or if you experience dizziness, feel like you’re going to faint, actually faint, have heavy vaginal bleeding, have trouble breathing, experience sudden confusion, or have pain at the tip of your shoulder. Do not wait for a physical therapy appointment. Do not drive; have someone accompany you or call 911 for an ambulance. NHS guidance on pelvic pain¹⁶ distinguish between these situations.

How does physical therapy help relieve vulvovaginal pain?

Pelvic physical therapy can reduce pain and improve sexual function by working on muscle control and relaxation, tolerance to touch, and a return to normal activities. It is specifically designed to treat induced vestibulodynia and overly tense pelvic muscles. The degree of improvement varies depending on the individual and the condition being treated.^{17, 18}

The initial assessment

Your pelvic floor physiotherapist will first conduct a complete evaluation:

• Discussion of your symptoms, concerns, and goals
• Assessment of your posture and breathing
• Pelvic floor examination (always with your consent)
• Identifying the factors that contribute to your pain

The Techniques Used

Depending on the evaluation results, your physiotherapist may use:

What the research shows:

Studies show benefits, though these are limited depending on the methodology used. A 2017 review noted that most studies either lacked a control group or had small sample sizes.¹⁷ A Canadian trial of 212 women with induced vestibulodynia¹⁹ then compared ten weeks of physical therapy—combining education, exercises with feedback, manual techniques, and dilators—to the nighttime application of lidocaine, a medication that numbs the area. Pain during intercourse was, on average, 1.8 points lower out of 10 in the physical therapy group after treatment, with the benefit persisting at six months. Sexual function and satisfaction also improved to a greater extent. A small follow-up study of 24 women, conducted approximately 13 years after physical therapy, found lasting improvements in several participants, including ten who reported having had no pain during intercourse since treatment. This follow-up is based on their recollections and does not include a comparison group.²⁰

A personalized approach

Each treatment plan is tailored to your specific needs and your own pace. You are always in control of what happens during the sessions.

What can you do at home to relieve vulvovaginal pain?

Slow breathing, a well-tolerated lubricant, and adjusting activities are measures you can try at home to reduce irritation and discomfort. Intimate relations can be adjusted if penetration is painful. These measures complement the evaluation and treatment.

Relaxation Techniques

• Breathe in slowly, allowing your belly to expand
• Let the muscles at the base of your pelvis relax, without pushing down
• Breathe out gently, allowing everything to return naturally
• Try a few comfortable breaths and work with your physical therapist to adjust the duration.

Meditation, gentle yoga, and walking can also be part of your relaxation routine. Physical therapy tips from Cambridge University Hospitals²¹ suggest breathing exercises, relaxation, and appropriate physical activity.

Hygiene Tips

• Avoid scented soaps and vaginal douches
• Choose cotton underwear
• Avoid overly tight clothing
• Gently wash the vulva with water—without cleaning inside the vagina—then pat it dry

For Intimate Relationships

• Communicate openly with your partner
• Use a well-tolerated, water-based lubricant that is fragrance-free and does not have a warming or cooling effect
• Explore other forms of intimacy that do not cause pain
• Go at your own pace, without any pressure

Pain management

• Apply a cool compress to the vulva, wrapped in a cloth; avoid direct contact with ice and stop if it causes irritation
• A lukewarm or cool bath, without scented products; avoid hot water
• Stress Management Activities

When can we expect to see an improvement in vulvovaginal pain?

Improvement in vulvovaginal pain may take several weeks or several months, depending on the cause and treatment. In the physical therapy trial for provoked vestibulodynia, benefits were assessed after ten weeks and were still present at six months. These benchmarks do not establish an individual recovery timeframe.

Factors That Help Tailor Monitoring

• How long you have had symptoms
• The cause(s) involved
• Exercise Tolerance and How to Incorporate Exercise into Your Daily Life
• Your general stress level

What to Expect

The pace of improvement varies greatly from person to person. Some women notice a change after a few weeks, while others need more time.

Positive Signs to Watch For

• Reduced pain during typical activities
• Improved awareness of your pelvic muscles
• Increased ability to relax this area
• Improved quality of life

Patience and progress

Symptoms can fluctuate. A significant worsening of symptoms, the appearance of new symptoms, or a lack of improvement are reasons to review your treatment plan with your healthcare provider, rather than automatically assuming that everything is part of the healing process.

Your vulvovaginal pain is real, even when its exact cause remains unknown. Pelvic physical therapy can help you reduce pain and resume important activities, in conjunction with other necessary treatments.

You deserve help and support. Don't hesitate to consult a physical therapist who specializes in pelvic floor rehabilitation to begin your journey toward better health.

Further Reading

• Pelvic Floor Physiotherapy
• Chronic Pelvic Pain Syndrome in Men
• Physical Therapy in Women's Health
• Postpartum Physical Therapy

What sources does this article draw on?

This article is based on the scientific studies, clinical guidelines, and reference materials listed below, which you or your healthcare provider can consult.

1. Hill DA, Taylor CA. Dyspareunia in Women. Am Fam Physician. 2021;103(10):597-604. ↩ Back to text
2. Morin M, Binik YM, Bourbonnais D, Khalifé S, Ouellet S, Bergeron S. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia. J Sex Med. 2017;14(4):592-600. ↩ Back to text
3. Volcheck MM, Graham SM, Fleming KC, Mohabbat AB, Luedtke CA. Central sensitization, chronic pain, and other symptoms: Better understanding, better management. Cleve Clin J Med. 2023;90(4):245-254. ↩ Back to text
4. Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy for the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019;31(6):485-493. ↩ Back to text
5. Bergeron S, Reed BD, Wesselmann U, Bohm-Starke N. Vulvodynia. Nat Rev Dis Primers. 2020;6(1):36. ↩ Back to text: 1st, 2nd citations
6. Vieira-Baptista P, Lima-Silva J, Cavaco-Gomes J, Beires J. Prevalence of vulvodynia and risk factors for the condition in Portugal. Int J Gynaecol Obstet. 2014;127(3):283-7. ↩ Back to text: 1st, 2nd, 3rd citations
7. Brown, B. Female Pelvic Conditions: Dyspareunia and Vulvodynia. FP Essent. 2024;547:8-15. ↩ Back to text
8. Murina F, Recalcati D, Di Francesco S, Cetin I. Effectiveness of Two Transcutaneous Electrical Nerve Stimulation (TENS) Protocols in Women with Provoked Vestibulodynia: A Randomized Controlled Trial. Med Sci (Basel). 2023;11(3). ↩ Back to text
9. Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;12(12):CD001760. ↩ Back to text
10. Kaplan CM, Kelleher E, Irani A, Schrepf A, Clauw DJ, Harte SE. Deciphering nociplastic pain: clinical features, risk factors, and potential mechanisms. Nat Rev Neurol. 2024;20(6):347-363. ↩ Back to text: 1st, 2nd citations
11. Awad-Igbaria Y, Edelman D, Ianshin E, Abu-Ata S, Shamir A, Bornstein J, et al. Inflammation-induced mast cell-derived nerve growth factor: a key player in chronic vulvar pain? Brain. 2025;148(1):331-346. ↩ Back to text
12. Mwaura AN, Marshall N, Anglesio MS, Yong PJ. Neuroproliferative dyspareunia in endometriosis and vestibulodynia. Sex Med Rev. 2023;11(4):323-332. ↩ Back to text
13. Keizer A, Vandyken B, Vandyken C, Yardley D, Macedo L, Kuspinar A, et al. Predictors of Pelvic Floor Muscle Dysfunction Among Women With Lumbopelvic Pain. Phys Ther. 2019;99(12):1703-1711. ↩ Back to text: 1st, 2nd citations
14. Nimbi FM, Renzi A, Mesce M, Limoncin E, Galli F. Symptoms of central sensitization in vulvodynia: exploring the role of temperament, personality traits, adverse childhood events, defense mechanisms, and mental pain on quality of life. J Sex Med. 2024;21(10):912-921. ↩ Back to text
15. Queiroz JF, Aquino ACQ, Sarmento ACA, Siqueira BB, Medeiros HD, Falsetta ML, et al. Psychosocial Factors Associated With Vulvodynia. J Low Genit Tract Dis. 2024;28(3):264-275. ↩ Back to text
16. nhs.uk. Pelvic pain. 2017. ↩ Back to text
17. Morin M, Carroll MS, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev. 2017;5(3):295-322. ↩ Back to text: 1st, 2nd citations
18. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev. 2022;10(2):209-230. ↩ Back to text
19. Morin M, Dumoulin C, Bergeron S, Mayrand MH, Khalifé S, Waddell G, et al. Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial. Am J Obstet Gynecol. 2021;224(2):189.e1-189.e12. ↩ Back to text
20. Jahshan-Doukhy, O., & Bornstein, J. Long-Term Efficacy of Physical Therapy for Localized Provoked Vulvodynia. Int J Womens Health. 2021;13:161-168. ↩ Back to text
21. Cambridge University Hospitals. Chronic pelvic pain in women—vulvodynia. ↩ Back to text

Our physical therapists defined the research strategy, plan, and clinical content of this article. An AI tool assisted with the literature review and text editing to ensure consistency in content and writing style.