The most common cause of pain in the vagina is vaginal infections. These are extremely common, and can most often be well managed by any well trained gynecologist. As a referral center for pain problems, we commonly see more unusual causes for pain, which include vulvar vestibulitis (when pain is at the opening of the vagina), cervical pain (often following trauma to the cervix such as laceration during childbirth, LEEP or cone treatments for abnormal Pap smears, or chronic cervical infection), and pain at the top end of the vagina after hysterectomy.
We see many cases of this kind of pain as "neuropathic pain," or pain that is caused by malfunction of the nerves supplying the painful tissue. This may mean that tiny nerve endings are buried in small areas of scar tissue, too small to be seen by an examiner. This may explain that the cervix or upper end of the vagina may look perfectly normal, but may be quite painful when touched gently with a cotton-tipped applicator during the examination.
We investigate problems like this starting with a thorough history and careful physical examination. We continue with diagnostic blocks (injections of local anesthetics) to both better diagnose the problem, and also in the hope that one or more such blocks may actually cause the mis-firing nerves to stop sending off pain signals.
We often also treat with nightly applications of topical anesthetics to the involved areas, as well as medications with effects on the central nervous system that have been found useful in treating neuropathic pain. In some instances, techniques such as alcohol injections to permanently deaden nerve endings or surgical revision of the top end of the vagina can be useful as well.
As in other problems of pelvic pain, the proper selection and administration of these treatments is best done by physicians trained and experienced in treating pelvic pain disorders.