Total vaginal necrosis (TVN) is a rare, late complication after radiation treatment that requires prolonged management. A 75-year-old woman with a history of whole pelvis and intracavitary radiotherapy (ICR) for squamous cell carcinoma stage IIB in 1981 (complete remission) and another 6th cycles of chemotherapy due to cervical recurrence in 2009 developed second local recurrence confirmed by cervical biopsy in 2012. The vaginal length had been extremely shortened due to atrophy. The patient received ICR (3000 cGy) for a month. Seven months after radiation, the patient suffered pelvic pain, foul-odored vaginal discharge and urinary leakage. Pelvic examination showed total necrotic change of vagina. Vaginal biopsy showed no evidence of malignancy. Despite a month of conservative treatment, symptoms aggravated and thus necessitated intensive inpatient treatment. Therapies included daily vaginal irrigation, dressing with chlorohexidine gluconate and saline, intravenous antibiotics, and pain control with oral opioid and NSAIDs. Only minimal surgical debridement was possible due to diffusely necrotic and friable epithelium. Two kinds of vaginal suppositories (estradiol/ lyophilized lactobacilli, and neomycin sulfate / nystatin / polymyxin B sulfate) were inserted daily alternatively. Medication dosage was tapered gradually after 3 months. Five months after treatment, the vaginal wall was significantly improved with pinkish normal-looking epithelium. Although no definitive treatment is proven optimal for TVN so far, several conservative options may help alleviate symptoms.