Vaginal pain: What's important to know?

Vaginal pain is not a diagnosis in itself, but a symptom that can be caused by infection, dryness of the vaginal mucosa, inflammation, trauma, dermatological disease, chronic pain syndrome, or pelvic pathology. In practice, patients often refer to discomfort at the vaginal entrance, pain in the vestibule, and deeper pelvic pain during intercourse as "vaginal pain." Therefore, the first clinical question is where exactly the pain is located.

It's especially important for a physician to distinguish between superficial pain upon touching or attempting to insert a tampon and deep pain upon penetration. Superficial pain is more common with vulvodynia, dryness, inflammation of the mucous membrane, dermatoses, irritation, or spasm of the pelvic floor muscles. Deep pain often suggests endometriosis, pelvic inflammatory disease, adhesions, space-occupying lesions, and some other pelvic conditions. [1]

The most common causes of vaginal symptoms with burning, irritation, odor, or discharge are bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. However, if laboratory tests do not confirm infection and signs of inflammation persist, non-infectious causes should also be considered: mechanical irritation, allergic reactions, estrogen deficiency, chronic pain, dermatoses, or concomitant pathology of the cervix and pelvic organs. [2]

After menopause and with severe estrogen deficiency, vaginal pain is often associated with genitourinary syndrome of menopause. It develops against the background of declining estrogen and androgen levels and is characterized by dryness, burning, microcracks, painful intercourse, and a decreased quality of life. Current guidelines from 2025 emphasize that diagnosis is based on symptoms, with or without physical signs, after excluding other causes and associated conditions. [3]

A particular difficulty is that vaginal pain is often associated with psychological stress, fear of pain, avoidance of sexual activity, and secondary exacerbation of pelvic floor muscle spasms. This does not make the complaint "psychosomatic" in the simplified sense, but merely demonstrates that chronic pain often becomes a complex problem, involving the mucous membrane, nerves, muscles, and emotional response to pain. [4]

Table 1. What is most often hidden behind the complaint of vaginal pain?

Pain variant	What is most often assumed first?	What helps to distinguish
Pain at the entrance to the vagina	Dryness, irritation, vulvodynia, pelvic floor hypertonicity, dermatoses	Increased by touch, tampon, sexual intercourse
Pain with itching, odor or discharge	Bacterial vaginosis, candidiasis, trichomoniasis	Inspection, acidity, microscopy, molecular tests
Postmenopausal pain	Genitourinary syndrome of menopause	Dryness, microtrauma, pain upon contact
Acute pain with fever	Infection, pelvic inflammatory disease, abscess	Urgency, general intoxication, pain on examination
Deep pain during intercourse	Endometriosis, pelvic pathology	Menstrual cycle association, pelvic pain, imaging findings
Pain with ulcers or blisters	Genital herpes and other ulcerative lesions	Visible elements, burning, painful urination

The table is compiled based on recommendations for pain during intercourse, diagnosis of vaginal symptoms, genitourinary syndrome of menopause, and genital herpes. [5]

The main causes of vaginal pain

Infectious vaginitis remains one of the most common causes of pain, burning, and discomfort. Bacterial vaginosis typically presents with a thin, uniform discharge and a characteristic odor, but severe pain is not always present. Candidiasis often causes more intense itching and burning, while trichomoniasis often combines symptoms with irritation, odor, pain during intercourse, and mucosal inflammation. [6]

Genital herpes can also present as a very painful "vaginal" rash, especially if the lesions are located at or near the vaginal opening. It is characterized by painful blisters and sores, burning, tingling, pain during urination, and sometimes general symptoms, including fever and swollen inguinal lymph nodes. This pain is usually sharper and more superficial than that associated with bacterial vaginosis or candidiasis. [7]

After menopause, and sometimes in the postpartum period, especially during breastfeeding, dryness and atrophic changes in the mucous membrane become a significant cause. This leads to microtrauma, burning, and pain during intercourse, and sometimes even just walking or sitting. Guidelines for genitourinary syndrome of menopause emphasize that local low-dose vaginal estrogen has the strongest evidence base among treatment methods, while for patients with hormone-dependent tumors, the solution is selected on an individual basis. [8]

Some patients suffer not from infection, but from chronic pain without visible inflammation. This group includes vulvodynia and localized, provoked pain in the vaginal vestibule. These are characterized by burning, stabbing, stabbing, or aching pain lasting at least 3 months, often with an apparently normal mucosa. In such cases, careful exclusion of infections and dermatoses, pain mapping with a cotton swab, and assessment of associated conditions, including pelvic floor muscle hypertonicity, are particularly important. [9]

Hypertonicity and tenderness of the pelvic floor muscles can, on their own, cause severe pain when inserting a finger, tampon, or speculum, or during intercourse. This pain is typically accompanied by a sensation of "stress" or spasm, pain in the lower back, groin, or thighs, and may be accompanied by difficulty urinating or defecating. This is an important cause that can be easily missed if only a smear test is performed without palpating the pelvic floor muscles. [10]

Finally, pain may be secondary to a deeper pelvic pathology. Pelvic inflammatory disease requires a low threshold of suspicion, as late diagnosis can compromise reproductive health. Endometriosis also often presents with pelvic pain and pain during intercourse, although a normal examination or even normal imaging does not always completely rule out this condition. Bartholin's cysts and abscesses are also important considerations, as they cause a painful swelling at the vaginal opening that rapidly worsens with infection. [11]

Table 2. Common causes and their typical symptoms

Cause	The most characteristic signs	What helps to confirm
Bacterial vaginosis	Odor, thin discharge, irritation	Amsel criteria, microscopy, acidity
Vulvovaginal candidiasis	Itching, burning, white discharge, pain	Microscopy, culture in complex cases
Trichomoniasis	Irritation, discharge, pain during sexual intercourse	Molecular tests, microscopy
Genital herpes	Painful blisters and ulcers, burning	Examination, smear from the lesion as indicated
Genitourinary syndrome of menopause	Dryness, microcracks, pain on contact	Inspection and exclusion of other causes
Vulvodynia	Chronic pain lasting more than 3 months, often without obvious external changes	Exclusion of other causes, pain mapping
Pelvic floor hypertonicity	Spasm, pain upon injection, sore muscles	Palpation of the pelvic floor muscles
Pelvic inflammatory disease	Pelvic pain, tenderness on examination, sometimes fever	Clinical evaluation, pregnancy is excluded first
Bartholin's abscess	Painful swelling on one side at the entrance to the vagina	Inspection

The table is based on guidelines for vaginal symptoms, pain with intercourse, pelvic inflammatory disease, and Bartholin's cyst.[12]

Risk factors and signs that require immediate action

Risk factors help quickly identify the likely cause of pain. The postpartum period, breastfeeding, peri- and postmenopause, depression, anxiety, previous trauma, pelvic floor surgery, and certain associated pain syndromes are significant predictors of painful intercourse and entry pain. For infections, sexual risk factors, disrupted vaginal environments, and self-medication with inappropriate medications are more significant. [13]

You should immediately consult a doctor if you experience fever, chills, rapidly increasing pain, purulent or foul-smelling discharge, significant swelling of the vaginal opening, or severe pain during examination. This diagnosis requires ruling out acute infection, pelvic inflammatory disease, abscess, and other conditions that should not be left untreated.

Sudden, severe pelvic pain in a woman of reproductive age is particularly worrisome. In this case, pregnancy, including ectopic pregnancy, as well as adnexal torsion and other acute gynecological conditions, must be ruled out before a definitive diagnosis is made. Guidelines on pelvic inflammatory disease explicitly state that the clinical threshold for diagnosis should be low, as delayed treatment increases the risk of complications.

Painful ulcers, rapidly growing fissures, dense infiltrates, vulvar skin changes, persistent postmenopausal bleeding, and suspicious lesions require the exclusion of dermatoses, precancerous, and neoplastic processes. The situation is especially concerning if the pain persists for a long time and standard pap smears and antifungal medications are ineffective.

A particular red flag is a painful swelling at the vaginal opening that, over the course of hours or days, becomes larger, hotter, redder, or develops pus or fever. This is typical of an infected Bartholin's cyst, or abscess, and requires urgent in-person examination rather than waiting at home. [14]

Table 3. Red flags for vaginal pain

Symptom	Why is it dangerous?
Fever, chills, rapidly increasing pain	Acute infection or pelvic inflammatory disease is possible
Sharp pelvic pain	It is necessary to exclude ectopic pregnancy, torsion and other acute causes.
Pus, strong odor, severe swelling	An abscess or severe inflammation is possible.
Painful, one-sided swelling at the entrance to the vagina	Bartholin's abscess is possible
Ulcers, cracks, thick areas of skin, spotting after menopause	Dermatoses and neoplasia must be excluded.
Pain for more than 3 months with no effect from standard treatment	It may be a chronic pain pathology, not an infection.

The table is compiled from the original page, the Pelvic Inflammatory Disease Guidelines and the National Health Service's Bartholin's Cyst Guidelines.

Diagnosis and differential diagnosis

Diagnosis begins with a very specific interview. It is important to determine the exact location of the pain, when the pain began, and whether it is related to sexual intercourse, the menstrual cycle, menopause, childbirth, breastfeeding, urination, itching, discharge, odor, new hygiene products, lubricants, condoms, medications, and past self-medication. Recommendations emphasize that history alone cannot accurately determine the causes of vaginal symptoms. [15]

The examination should be gradual and gentle. First, the skin and mucous membranes are assessed for erythema, ulcers, vesicles, fissures, dryness, and discharge. For localized pain, gentle, consistent touching with a cotton swab is used to determine the point of maximum tenderness. Then, if necessary, a digital examination is performed to assess pelvic floor muscle tenderness and a bimanual examination is performed to identify a deep pelvic cause. [16]

If infection is suspected, basic diagnostics include pH testing, potassium hydroxide testing, microscopy of a swab, and, if necessary, more sensitive molecular tests. Increased pH over 4.5 is more common with bacterial vaginosis or trichomoniasis. The absence of fungi or trichomonas on microscopy does not rule out these infections, so if symptoms persist and the swab is negative, more accurate methods are required. [17]

If the pain is deeper, significantly associated with sexual intercourse, menstruation, or accompanied by pelvic pain, further diagnostic workup is necessary. If pelvic inflammatory disease is suspected, cervical, uterine, or adnexal tenderness during examination is important. When endometriosis is suspected, a detailed history and imaging, particularly ultrasound, are increasingly important. However, a normal examination and even normal imaging do not always completely rule out the disease. [18]

If vulvar dermatoses are suspected, a biopsy may be necessary, and if symptoms persist without a clear cause, referral to a chronic vulvar pain specialist, pelvic floor specialist, or gynecologist specializing in pain management should be considered. This is especially important when repeated courses of antifungal or antibacterial medications are ineffective and it becomes apparent that the complaint is non-infectious in nature. [19]

Table 4. What is usually included in the examination

Method	When it is especially useful	What does it give?
Detailed survey	To all patients	Helps to determine the type of pain and provoking factors
Examination of the vulva and vagina	To all patients	Shows inflammation, dryness, ulcers, cracks, swelling
Pain mapping with a cotton swab	For localized entry pain	Helps identify localized pain
Palpation of the pelvic floor muscles	If there is pain during insertion and a feeling of spasm	Detects hypertonicity and myofascial pain
Acidity, microscopy, potassium hydroxide test	In case of discharge, odor, burning	Helps differentiate between bacterial vaginosis, candidiasis, and trichomoniasis
Molecular tests	In doubtful or recurrent cases	More sensitive detection of pathogens
Pregnancy test	For acute pelvic pain in women of reproductive age	Helps rule out ectopic pregnancy
Ultrasound and other imaging	For deep pelvic pain, suspected endometriosis or complications	Clarifies the pelvic cause
Biopsy	For suspicious skin changes	Helps confirm dermatosis or neoplasia

The table is based on recommendations from the Centers for Disease Control and Prevention, a review of pain with intercourse, and the 2024 endometriosis guidelines.[20]

Treatment

Treatment depends on the cause, not the pain itself. The most common mistake is repeated self-administration of antifungal suppositories or antibacterial agents without a confirmed diagnosis. The Centers for Disease Control and Prevention specifically notes that a medical history without examination and laboratory confirmation often leads to inappropriate treatment of vaginal symptoms. [21]

For bacterial vaginosis, the recommended regimens remain metronidazole 500 milligrams orally twice daily for 7 days, or metronidazole gel 0.75% once daily for 5 days, or clindamycin cream 2% at night for 7 days. There is no evidence that oral therapy is superior to topical therapy for symptomatic bacterial vaginosis, so the choice is made based on tolerability and the clinical situation. [22]

For vulvovaginal candidiasis, short courses of topical azoles or a single dose of 150 milligrams of fluconazole are typically used for uncomplicated cases. If symptoms persist after over-the-counter treatment or return within less than 2 months, an in-person evaluation and confirmation of the diagnosis are necessary. The Centers for Disease Control and Prevention also emphasizes that probiotics and homeopathic remedies do not have a strong evidence base for the treatment of candidiasis. [23]

For trichomoniasis, women are recommended to take metronidazole, 500 milligrams twice daily for 7 days, and treatment of partners is mandatory, otherwise the risk of reinfection remains high. This 7-day regimen for women has shown greater efficacy than a single high dose, and it is reflected in current recommendations from the Centers for Disease Control and Prevention. [24]

If pain is due to genitourinary syndrome of menopause, vaginal moisturizers and lubricants are the first line of treatment, followed by topical hormonal treatments for more severe symptoms. The 2025 guidelines emphasize that topical low-dose vaginal estrogen has the strongest evidence base. For patients with hormone-dependent breast cancer, therapy is individualized after discussing non-hormonal and hormonal options, risks, and benefits. [25]

For vulvodynia and pain associated with pelvic floor hypertonicity, a multidisciplinary approach is recommended. Most commonly recommended are avoidance of irritants, gentle care, pelvic floor physiotherapy, cognitive behavioral therapy, and, in selected cases, topical lidocaine, pain-modulating medications, and, in carefully selected patients with localized, evoked pain, surgical treatment. For deep pain associated with endometriosis, analgesia and hormonal therapies are used, and for pelvic inflammatory disease, antibacterial therapy is initiated according to clinical criteria, without waiting for severe complications. [26]

Table 5. Treatment for the most likely cause

Cause	Basic approach
Bacterial vaginosis	Metronidazole orally or topically, or clindamycin topically
Vulvovaginal candidiasis	Topical azoles or fluconazole for uncomplicated cases
Trichomoniasis	Metronidazole for 7 days in women; treatment of partners is mandatory.
Genital herpes	Confirmation of diagnosis and antiviral therapy according to the clinical situation
Genitourinary syndrome of menopause	Moisturizers, lubricants, topical estrogen, or other approved options
Vulvodynia	Gentle care, pelvic floor physiotherapy, and chronic pain management
Pelvic floor hypertonicity	Physiotherapy, relaxation training, sometimes trigger point therapy and neuromodulation
Pelvic inflammatory disease	Rapid clinical recognition and antibacterial therapy
Bartholin's abscess	Urgent in-person examination, drainage if necessary

The table summarizes current recommendations for vaginal infections, genitourinary syndrome of menopause, chronic pain, and pelvic inflammatory disease. [27]

Prevention and prognosis

Prevention begins with avoiding unnecessary irritants. Frequent douching, harsh detergents, scented pads, tight synthetic underwear, and rough intravaginal manipulation disrupt the mucous membrane and can perpetuate pain even without infection. For patients with chronic entry pain, recommendations for gentle care and minimizing friction are considered a basic part of treatment. [28]

To prevent recurrence of infections, accurate diagnosis and completion of the full course of treatment are important. In the case of trichomoniasis, treatment of partners is mandatory. In the case of candidiasis, frequent recurrences require not endless self-treatment, but confirmation of the diagnosis and identification of predisposing factors, including diabetes mellitus and frequent antibiotic use. [29]

After menopause and in situations of estrogen deficiency, it's helpful to avoid waiting for severe dryness and microtrauma to develop, and to discuss symptomatic therapy early. Genitourinary syndrome of menopause is a chronic and progressive condition, so lack of treatment usually leads to persistent or worsening pain and discomfort rather than spontaneous improvement. [30]

The prognosis depends largely on the underlying cause. Infectious and atrophic variants, if properly diagnosed, usually respond well to treatment. Chronic pain syndromes, such as vulvodynia and myofascial pelvic floor pain, require more patience and often do not resolve immediately, but with consistent rehabilitation, quality of life can be significantly improved. The worst-case scenario is months of self-medication without a clear diagnosis, when the true cause remains undetected. [31]

Questions and Answers

1. Are vaginal pain and vulvar pain the same thing?
No. Patients often confuse these complaints, but clinically, they are distinct areas, and their causes often differ.

2. If there is itching and burning, is it almost always a yeast infection?
No. The same symptoms can be caused by bacterial vaginosis, trichomoniasis, herpes, irritation, dryness of the mucous membrane, and chronic pain. [32]

3. Can a diagnosis be made based solely on discharge and odor?
No. Guidelines clearly state that a medical history alone is not enough, and without examination and testing, treatment is often inappropriate. [33]

4. When should you seek urgent medical attention?
Fever, sudden increase in pain, purulent discharge, painful swelling, severe pelvic pain, ulcers, or suspicious spotting after menopause.

5. Can pain be related to menopause, even if there is almost no discharge?
Yes. Estrogen deficiency can cause dryness, microcracks, and soreness without a clear infection. [34]

6. Does pain when inserting a tampon always indicate an infection?
No. This complaint is often associated with vulvodynia and hypertonicity of the pelvic floor muscles. [35]

7. Why do antifungal suppositories sometimes fail?
Because the cause may not be candidiasis, but bacterial vaginosis, trichomoniasis, dermatitis, dryness, herpes, or chronic pain. [36]

8. Should my partner be treated?
For trichomoniasis, yes, it's essential. For candidiasis and bacterial vaginosis, the approach is different and depends on the situation. [37]

9. Can endometriosis cause vaginal pain?
Yes, especially deep pain during intercourse and pelvic pain. A normal examination does not always rule it out. [38]

10. What if the smears are normal, but the pain persists for months?
It's necessary to expand the diagnostics and consider non-infectious causes: vulvodynia, dermatoses, pelvic floor hypertonicity, estrogen deficiency, endometriosis, and other pelvic conditions. [39]