Botox Pelvic Floor Injections for Refractory Vaginismus: A Case Study
Case Study Series
Pain Medicine — Vaginismus & Vestibulodynia
Reclaiming intimacy from vaginismus with Botox pelvic floor injections
A case study exploring how targeted intramuscular Botox, specialist pelvic floor physiotherapy, and a multidisciplinary approach transformed one patient’s quality of life.
4.5 yrs
Duration of symptoms
200u
Botox units delivered
8 wks
To significant improvement
✓
Pain-free intercourse achieved
Claire — Age 34, Midlands
Secondary School Teacher • Vestibulodynia & vaginismus • Hypothyroidism • Self-pay patient
Provoked vestibulodynia
Pelvic floor hypertonicity
Neuropathic pelvic pain
Significant improvement post-Botox
The Presentation
Years of pain that conventional treatments could not resolve
Claire, a 34-year-old secondary school teacher from the East Midlands, had been living with significant pelvic pain for over four and a half years. What had begun as pain during intercourse had gradually evolved into a more complex and wide-ranging symptom picture that affected her daily life, her intimate relationship, and her emotional wellbeing.
She described a spontaneous burning sensation at the vaginal entrance, as well as deeper pain that could come on with activities as ordinary as sitting for extended periods or cycling. She also noticed a burning sensation with urination, and had always found tampon use painful. The pain was localised to the vaginal area and did not radiate elsewhere. While intercourse had been possible on some occasions in the past, it had become increasingly difficult and distressing. She had never been pregnant.
Claire had already engaged actively with the healthcare system before reaching PainSpa. She had been reviewed by a Consultant Gynaecologist, who performed an internal examination. No structural abnormalities were identified, but significant hypertonicity of the pelvic floor muscles was noted. She had been attending weekly pelvic floor physiotherapy sessions, including breathing exercises, targeted stretches, and trigger point release. She had also trialled topical Lidocaine cream, without meaningful benefit. She was taking Amitriptyline 20mg nightly alongside Levothyroxine for hypothyroidism.
Despite this commendable engagement with conservative management, her symptoms persisted. It was at this point that she was referred for specialist pain medicine input with Dr Murli Krishna at PainSpa.
Clinical Background
Understanding vaginismus and the role of pelvic floor hypertonicity
Vaginismus is a complex pain condition characterised by involuntary contraction or spasm of the muscles surrounding the vaginal entrance, making penetration — including intercourse, tampon use, and gynaecological examination — painful or impossible. It is closely related to vestibulodynia, a condition in which pain arises specifically at or around the vestibular entrance to the vagina, often with a burning or neuropathic quality.
These conditions are frequently misunderstood, underdiagnosed, and undertreated. Patients often spend years navigating a fragmented care pathway before receiving an accurate diagnosis and appropriate treatment. The psychological burden of chronic pelvic pain — including its impact on intimate relationships, self-esteem, and mental health — should not be underestimated.
The role of pelvic floor hypertonicity in vaginismus
Puborectalis muscle
A key component of the levator ani muscle group. Excessive tone here significantly narrows the vaginal canal and contributes to pain during penetration.
Pubococcygeus & iliococcygeus
The deeper pelvic floor muscles. Hypertonicity here creates a cycle of tension and pain which can become self-perpetuating without targeted intervention.
Vestibular entrance
Peripheral sensitisation at the vestibule generates pain from normally innocuous stimuli. This neuropathic component often persists alongside muscular hypertonicity.
The pain-spasm cycle
Anticipated or actual pain triggers protective muscle guarding, which itself causes further pain — a cycle that conventional treatments alone may struggle to break.
Symptom Assessment
A picture of provoked and spontaneous vestibulodynia
Claire’s symptom profile was consistent with provoked vestibulodynia with a spontaneous component — a pattern in which pain arises primarily with contact or pressure, but may also occur without direct provocation.
Provoked pain
Contact and activity-triggered
Pain during intercourse • Pain with tampon insertion • Pain when sitting for extended periods • Pain with cycling
Spontaneous pain
Unprovoked & background
Burning at vaginal entrance without contact • Deeper pelvic discomfort • Burning with urination • Sensitivity with tight clothing
Muscular component
Pelvic floor hypertonicity
Tenderness at vestibular entrance • Hypertonicity confirmed on examination • Partial response to physiotherapy • Pelvic floor unable to fully relax
Neuropathic features
Sensitisation at the vestibule
Burning quality • Allodynia — pain from normally non-painful stimuli • Persisting despite antineuropathic medication • No radiation to buttocks or anal region
Failed conservative management — an indication for interventional treatment
Claire had engaged fully with antineuropathic medication, topical anaesthesia, and specialist pelvic floor physiotherapy over an extended period. The persistence of symptoms made her an appropriate candidate for interventional pain medicine.
The Treatment Journey
A structured, stepwise approach to recovery
Dr Krishna’s approach was grounded in thorough assessment, transparent discussion of options, and a carefully sequenced treatment plan — not a standalone fix, but a catalyst for rehabilitation.
September 2025 — Initial Consultation (Videolink)
Comprehensive assessment and diagnosis
Dr Krishna conducted a detailed video consultation, reviewing Claire’s full symptom history, previous investigations, and all treatments tried to date. He formulated a clinical diagnosis of provoked vestibulodynia with a spontaneous component, underpinned by significant pelvic floor hypertonicity. Two management options were discussed: Botox trigger point injections and pudendal nerve blocks.
September 2025 — Shared Decision-Making
Honest expectation-setting before proceeding
Dr Krishna was careful to set realistic expectations. Claire was informed that Botox injections typically take 2-4 weeks to have meaningful impact on pain, that some patients require repeat injections at 2-3 months for sustained benefit, and that pelvic floor physiotherapy and progressive dilator use would remain essential components of her recovery.
February 2026 — Botox Pelvic Floor Injections
200 units of Botox delivered to targeted pelvic floor muscles
Claire attended the Willow Surgery clinic in Downend, Bristol. Dr Krishna performed Botox trigger point injections through the vaginal wall, targeting the puborectalis muscle, the vestibular entrance, and the deeper pubococcygeus and iliococcygeus muscles bilaterally — 200 units in total. She was advised to begin dilator use after two weeks and to defer intercourse for at least 3-4 weeks.
April 2026 — Eight-Week Follow-Up
Significant and meaningful improvement confirmed
At her follow-up approximately eight weeks after the procedure, Claire reported a clinically significant improvement. Deep pain with dilator use and during intercourse had resolved. She had progressed to larger dilator sizes without pain. Sensitivity around the vestibular entrance had also reduced, though some discomfort at the vestibule itself persisted. Further targeted Botox at the vestibular entrance was agreed as the next step.
The PainSpa Approach
Four pillars of vaginismus management at PainSpa
Vaginismus and vestibulodynia are complex, multifactorial conditions. Effective management requires more than a single intervention. Dr Krishna’s approach integrates precision pain medicine with a genuine commitment to multidisciplinary care.
1. Precise clinical assessment
A thorough evaluation of the muscular, neuropathic, and functional contributors to each patient’s pain before any injection is planned.
2. Targeted Botox intervention
Precisely placed intramuscular Botox injections to reduce pelvic floor hypertonicity — breaking the pain-spasm cycle and enabling rehabilitation.
3. Pelvic floor physiotherapy
Specialist physiotherapy is an essential component of care. Botox creates the opportunity — physiotherapy, dilator progression, and exercises deliver the lasting gains.
4. Psychological support
Chronic pelvic pain carries a significant psychological burden. Psychosexual therapy and CBT are often a vital part of the recovery pathway.
Botox injections do not cure vaginismus on their own — they break the pain-spasm cycle, creating a window in which rehabilitation can truly begin. The physiotherapist, the patient, and in many cases a psychologist, are just as important as the injection itself.
Dr Murli Krishna — Consultant in Pain Medicine, PainSpa
The Multidisciplinary Perspective
Why psychological input matters in vaginismus
Vaginismus does not exist in isolation. For many patients, chronic pelvic pain generates significant anxiety, avoidance behaviours, and negative cognitive patterns that become self-reinforcing over time. Anticipatory fear of pain can itself trigger pelvic floor spasm, perpetuating the cycle even when the underlying physical cause is being addressed.
Psychological support — in the form of psychosexual therapy, cognitive behavioural therapy (CBT), or mindfulness-based approaches — can help patients to break these patterns, rebuild confidence around intimacy, and engage more fully with the physical rehabilitation process. The combination of interventional pain medicine, specialist physiotherapy, and psychological support consistently produces the best outcomes.
Partners are often significantly affected, and couples therapy or joint psychosexual support can be profoundly valuable. Dr Krishna considers psychological input a clinical priority — not an optional add-on — for patients where it is indicated.
Outcome
What changed for Claire at eight weeks
Approximately eight weeks following her Botox pelvic floor injections, Claire returned for follow-up and reported meaningful and clinically significant improvement. For a patient who had spent four and a half years unable to have pain-free intercourse, the changes were striking.
Key improvements at eight-week follow-up
● Deep pelvic pain during intercourse resolved — intercourse now possible without deep pain
● Pain with dilator use resolved — able to progress to larger dilator sizes without discomfort
● Significant reduction in overall vestibular sensitivity, particularly with pressure and tight clothing
● Pain-spasm cycle interrupted — pelvic floor muscles able to relax to a degree not previously achievable
● Improved ability to engage with pelvic floor rehabilitation and progressive dilator use
● Residual pain localised to the vestibular entrance — the target of the next treatment step
Dr Krishna was particularly encouraged by the resolution of deep pain, reflecting successful relaxation of the deeper pelvic floor muscles. The ability to progress with dilators represents a meaningful functional gain demonstrating the muscles are now capable of the relaxation necessary for eventual pain-free intercourse.
Looking Ahead
The next steps in Claire’s recovery
The first round of Botox injections has achieved its primary objective. The next phase is targeted and clearly defined.
Recommended ongoing management plan
Next stepFurther Botox trigger point injections specifically targeting the vestibular entrance.
OngoingContinued pelvic floor physiotherapy — progressive dilator use, muscle relaxation exercises, and trigger point release.
IntercourseTo be approached gradually and attempted only when dilator use at an appropriate size is comfortable.
ReserveBilateral pudendal nerve blocks under ultrasound guidance if neuropathic sensitivity persists.
WellbeingPsychological support — psychosexual therapy or CBT to address anticipatory anxiety and support recovery.
Follow-upEight-week follow-up appointment planned following the next intervention.
Your Specialist
About Dr Murli Krishna
Dr Murli Krishna
Consultant in Pain Medicine — PainSpa
MBBS • FRCA • FFPMRCA • Fellow of the Faculty of Pain Medicine
Dr Krishna is a highly experienced Consultant in Pain Medicine practising at PainSpa’s clinics in Bristol, including Willow Surgery in Downend and the Chesterfield Nuffield Hospital in Clifton. He has a specialist interest in complex pelvic pain conditions including vaginismus, vestibulodynia, and pudendal neuralgia.
His approach is grounded in a thorough understanding of the muscular, neuropathic, and psychological contributors to each patient’s condition. He works closely with specialist pelvic floor physiotherapists and signposts patients to appropriate psychological support, recognising that the best outcomes are achieved through coordinated, team-based care.
Dr Krishna consults in person and via telephone or videolink. Patients wishing to explore Botox pelvic floor injections or other interventional treatments for vaginismus are encouraged to contact PainSpa to arrange an initial assessment.
Please note: This case study is published for educational and informational purposes. All patient-identifying details have been changed to protect confidentiality. Individual results vary; the procedure does not guarantee improvement. Botox injections are most effective as part of a comprehensive plan including physiotherapy and, where appropriate, psychological support. This does not constitute medical advice. For queries write to clinic@painspa.co.uk.
Painspa
Willow Surgery, Downend • Chesterfield Nuffield, Clifton • clinic@painspa.co.uk • www.painspa.co.uk
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