Clinical Effects of Pelvic Floor Transcutaneous Electrical Nerve Stimulation on Pain and Sexual Function in Dyspareunia: A Case Series

Clinical Effects of Pelvic Floor Transcutaneous Electrical Nerve Stimulation on Pain and Sexual Function in Dyspareunia: A Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Effects of Pelvic Floor Transcutaneous Electrical Nerve Stimulation on Pain and Sexual Function in Dyspareunia: A Case Series Lara Freitas Matos Costa, Heloísa Cristina Barbosa de Santana, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9347276/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Dyspareunia is characterized by pain occurring before, during, or after sexual intercourse and has a multifactorial etiology involving biological, hormonal, and psychosocial factors. It can significantly impair quality of life and sexual well-being. Purpose To evaluate the effects of transcutaneous electrical nerve stimulation (TENS) combined with pelvic floor muscle training on pain, sexual function, self-esteem, and quality of life in women with dyspareunia. Methods This case series included seven women with dyspareunia assessed before and after a five-session intervention protocol. The intervention consisted of TENS combined with pelvic floor muscle training. Outcomes included pain (Visual Analog Scale), sexual function (Female Sexual Function Index), self-esteem (Rosenberg Self-Esteem Scale), and quality of life (SF-36). Results A statistically significant reduction in pain was observed (p = 0.031). No significant improvements were found in sexual function or quality of life. Conclusion TENS combined with pelvic floor muscle training may reduce pain in women with dyspareunia; however, no improvements were observed in sexual function or quality of life. Further controlled studies are required. dyspareunia transcutaneous electrical nerve stimulation pelvic floor sexual dysfunction physical therapy modalities Figures Figure 1 Figure 2 Figure 3 Introduction Sexual health is defined by the World Health Organization as a state of physical, emotional, mental, and social well-being in relation to sexuality, extending beyond the mere absence of disease or dysfunction. Within this framework, dyspareunia—characterized by recurrent or persistent genital pain associated with sexual activity—is a prevalent form of female sexual dysfunction with a multifactorial etiology involving biological, hormonal, and psychosocial components ( 1 , 2 ). Clinically, dyspareunia may be classified as superficial, typically involving vulvar or introital pain, or deep, when pain is localized to pelvic structures such as the cervix, bladder, or lower pelvis ( 3 , 4 ). The etiology of dyspareunia is complex and includes organic conditions such as endometriosis, pelvic infections, perineal trauma, and vaginal atrophy, as well as hormonal factors, particularly hypoestrogenism, and psychosocial contributors including anxiety, depression, and prior sexual trauma. Prevalence estimates vary widely depending on population and assessment methods, ranging from 1% to over 50%, reflecting both methodological heterogeneity and the multifactorial nature of the condition ( 2 ). Despite its clinical relevance, there remains a lack of high-quality evidence regarding effective therapeutic interventions, particularly among adolescent and young adult populations. Dyspareunia has substantial implications for multiple domains of women’s health, including sexual function, psychological well-being, self-esteem, and interpersonal relationships. Pain during sexual activity may lead to avoidance behaviors, emotional distress, and significant impairment in quality of life, reinforcing the need for evidence-based, multidimensional therapeutic approaches ( 5 ). Pelvic floor physical therapy has emerged as a key component in the management of female sexual dysfunction, particularly through interventions targeting pelvic floor muscle function. These approaches aim to modulate pain, restore muscle coordination, and improve body awareness—factors essential for sexual function recovery ( 6 , 7 ). Recent systematic reviews have demonstrated that pelvic floor muscle training is associated with improvements in pain, sexual function, and quality of life in women with sexual dysfunction ( 3 , 8 , 9 ). Transcutaneous electrical nerve stimulation (TENS) has been proposed as a non-invasive therapeutic modality with potential benefits in pain modulation and neuromuscular function. Its analgesic effects are primarily explained by the gate control theory and the activation of endogenous opioid pathways, leading to reduced nociceptive transmission ( 10 – 12 ). Additionally, TENS may enhance local blood flow, reduce muscle hypertonicity, and decrease tissue hypersensitivity, thereby contributing to pelvic floor rehabilitation ( 13 ). However, despite its physiological plausibility and increasing clinical use, evidence regarding its effectiveness in dyspareunia remains limited and inconsistent, particularly in non-invasive transcutaneous applications. Given the clinical relevance of dyspareunia and the limited evidence regarding non-invasive therapeutic strategies, this study aimed to evaluate the clinical effects of TENS combined with pelvic floor muscle training on pain, sexual function, self-esteem, and quality of life in adolescent and adult women with dyspareunia. This investigation was designed as an exploratory case series to provide preliminary clinical insights into the role of TENS as a physical therapy modality in the management of sexual pain disorders. Materials and Methods This study was designed as an exploratory case series following CARE guidelines adapted for case series reporting. Ethical approval was obtained from the Research Ethics Committee of the Hospital das Clínicas, Federal University of Pernambuco (protocol no. 4.840.515). The study was conducted at the Family Planning Clinic and the Gestational Trophoblastic Disease Clinic of the Hospital das Clínicas of the Federal University of Pernambuco (HC-UFPE), and at the Electrothermophototherapy Laboratory (LETER) of the Physiotherapy Department. A convenience sample was recruited from outpatient clinical settings and institutional advertisements. Data collection was carried out between September 2024 and November 2025. Eligible participants were adolescent and adult women aged 13 to 40 years who reported pain occurring before, during, or after sexual intercourse and had a clinical diagnosis of dyspareunia of any etiology. Inclusion criteria comprised being sexually active and able to complete study assessments. Women with postpartum dyspareunia (within one year after delivery) were also included. For participants under 18 years of age, both informed assent and parental consent were obtained. Exclusion criteria included inability to understand or complete questionnaires, presence of active sexually transmitted infections, chronic vulvar disorders, prior oophorectomy or oophoroplasty, contraindications to electrical stimulation (including implanted electronic devices such as pacemakers), and current pregnancy. Outcome Measures Participants underwent baseline clinical assessment followed by standardized evaluation using validated instruments. Pain intensity was assessed using the Visual Analog Scale (VAS). Sexual function was measured using the Female Sexual Function Index (FSFI), with scores below 26.55 indicating sexual dysfunction. Self-esteem was evaluated using the Rosenberg Self-Esteem Scale, and quality of life was assessed using the 36-Item Short Form Health Survey (SF-36). All instruments were previously validated for use in the Brazilian population ( 14 ). Data Collection Procedures Eligible participants provided written informed consent prior to participation. Baseline assessments included sociodemographic data and administration of all outcome measures. Participants meeting inclusion criteria proceeded to the intervention phase. Intervention Protocol Participants received an intervention consisting of pelvic floor muscle training combined with transcutaneous electrical nerve stimulation (TENS). Initially, participants were instructed on pelvic floor anatomy and muscle awareness. The exercise protocol consisted of three sets of ten sustained contractions, each held for six seconds, with 30-second rest intervals between sets. Following the exercise session, TENS was applied transcutaneously to the perineal region using surface electrodes positioned bilaterally over the pubic area. Stimulation parameters were based on previous studies and included a frequency of 110 Hz and pulse duration of 80 µs. Intensity was adjusted individually to the maximum comfortable sensory threshold without inducing pain. The intervention was performed once weekly over five consecutive weeks. All participants were reassessed after completion of the intervention using the same outcome measures applied at baseline. Statistical Analysis Statistical analyses were performed using SigmaPlot version 12.0 (Systat Software Inc., San Jose, CA, USA). Data were expressed as mean ± standard deviation (SD) for continuous variables. Given the small sample size and paired study design, within-subject comparisons were conducted between baseline and post-intervention measurements. The normality of data distribution was assessed using the Shapiro–Wilk test. For variables with normal distribution, paired Student’s t-test was applied. For variables that did not meet normality assumptions, the non-parametric Wilcoxon signed-rank test was used. Mean differences and corresponding 95% confidence intervals (95% CI) were calculated when applicable. A two-tailed significance level of p < 0.05 was adopted for all analyses. Due to the exploratory nature of this case series and the limited sample size (n = 7), the results should be interpreted with caution, and no adjustment for multiple comparisons was performed. Effect sizes were not calculated due to the exploratory nature of the study. Results Seven women with dyspareunia were included in this case series and completed the intervention protocol. Primary outcomes were pain, sexual function, and self-esteem, while quality of life was considered a secondary outcome. All variables were assessed before and after the intervention. Table 1 . Baseline characteristics of participants (n = 7) Table 1 Baseline characteristics of participants (n = 7) Variable Mean ± SD/n (%) Age 26.7 ± 5.8 Race Yellow 1 ( 14 ) White 1 ( 14 ) Black 5 (72) Marital status Single 5 (72) Married/Partnered 2 (28) Educational Level Basic/Secondary education 2 (28) Higher education (incomplete/complete) 5 (72) Monthly income, n (%) ≤ 1 minimum wage 3 (43) 2 to 5 minimum wages 3 (43) No income 1 ( 14 ) Occupation, n (%) Student 3 (43) Unemployed 2 (29) Other 2 (28) Residence, n (%) Metropolitan region 7 (100) Data are presented as mean ± standard deviation (SD) or number of participants (percentage). Percentages may not total 100% due to rounding. The mean age of participants was 26.7 ± 5.8 years. Most participants were single (72%) and had incomplete higher education (58%), with a family income of up to five minimum wages (86%). Sociodemographic characteristics are presented in Table 1 . Reproductive characteristics are summarized in Table 2 . Table 2 Reproductive and obstetric characteristics of participants (n = 7) Variable n (%) Number of pregnancies 0 4 (58) 1 1 ( 14 ) 2 2 (28) Number of children 0 4 (58) 1 2 (28) 2 1 ( 14 ) Prenatal Yes 3 (43) No, not applicable 4 (57) Local prenatal care Public 3 (43) Not applicable 4 (57) Route of birth Vaginal 3 (43) Not applicable 4 (57) Perineal trauma Yes 3 (43) Not applicable 4 (57) Data are presented as number of participants (percentage). Categories marked as “not applicable” refer to participants with no prior pregnancy. Table 2 . Reproductive and obstetric characteristics of participants (n = 7) Pain intensity assessed by the Visual Analog Scale (VAS) showed a statistically significant reduction after the intervention (Fig. 1 ). Mean values decreased from 8.0 ± 1.2 at baseline to 4.0 ± 3.4 post-intervention. The mean difference was 4.0 points (95% CI: 0.5 to 7.5; p = 0.031). Increased variability was observed in post-intervention scores. Sexual function, assessed using the Female Sexual Function Index (FSFI), showed a slight decrease from 22.09 ± 4.57 to 21.74 ± 1.85 after the intervention (Fig. 2 ). This difference was not statistically significant (p = 0.375). A reduction in variability was observed in post-intervention scores. Self-esteem scores increased from 13.9 ± 4.0 at baseline to 15.9 ± 2.9 post-intervention, without statistical significance (p = 0.156) (Fig. 3 ). A reduction in variability was observed after the intervention. Quality of life assessed by the SF-36 showed a reduction in scores across all domains after the intervention. Most differences were not statistically significant (Table 3 ). A significant reduction was observed only in the functional capacity domain, which decreased from 63.6 ± 14.4 to 55.7 ± 16.7 (p = 0.033). The pain domain decreased from 42.1 ± 19.7 to 38.1 ± 19.3, without statistical significance. Table 3 Comparison of quality of life domains (SF-36) before and after intervention in women with dyspareunia (n = 7). Variable Before (Mean ± SD) After (Mean ± SD) Mean Difference (95% CI) P-value Functional Capacity 63.6 ± 14.4 55.7 ± 16.7 -7.9 (-14.9 to -0.9) 0.033* Limitations due to physical aspects 25.0 ± 38.2 21.4 ± 39.3 3.6 (-5.2 to 12.3) 1.000 # Pain 42.1 ± 19.2 38.1 ± 19.3 4.0 (-0.9 to 8.9) 0.250 # General Health Status 40.0 ± 24.6 35.1 ± 18.7 4.9 (-5.5 to 5.2) 0.295 Vitality 30.0 ± 18.5 25.0 ± 11.2 5.0 (-8.6 to 18.6) 0.403 Social Aspects 50.0 ± 17.7 41.1 ± 22.5 8.9 (-3.9 to 21.8) 0.250 # Emotional Aspects 23.8 ± 25.2 14.3 ± 26.2 9.5 (-24.8 to 43.8) 0.625 # Mental Health 35.4 ± 26.5 32.0 ± 12.7 3.4 (-15.2 to 22.1) 0.669 Data are presented as mean ± standard deviation (SD) and mean difference (95% confidence interval). Statistical comparisons were performed using paired Student’s t-test or Wilcoxon signed-rank test, as appropriate. *p < 0.05 indicates statistical significance. Table 3 . Comparison of quality of life domains (SF-36) before and after intervention in women with dyspareunia (n = 7). Discussion The findings of this study demonstrated a statistically significant reduction in perineal pain following the intervention with TENS, accompanied by a non-significant trend toward improvement in self-esteem. In contrast, sexual function scores and certain domains of quality of life showed reductions, including a statistically significant decrease in functional capacity. The observed reduction in pain is consistent with previous evidence supporting the use of TENS in the management of dyspareunia and chronic pelvic pain ( 17 , 18 ). However, in contrast to prior studies reporting improvements in quality of life following electrotherapy, the present findings did not demonstrate similar benefits ( 3 , 19 ). These discrepancies highlight the variability of clinical responses and reinforce the exploratory nature of the present study. Despite evidence suggesting that electrical stimulation may improve sexual function, the present study did not demonstrate significant improvement in FSFI scores and observed a slight reduction following the intervention. This finding may be influenced by unmeasured variables known to affect sexual function, including hormonal fluctuations, psychological stress, and contextual factors, which are frequently associated with dyspareunia and may modulate treatment response ( 17 ). Furthermore, studies employing intravaginal electrical stimulation have reported more consistent improvements in sexual function, suggesting that differences in stimulation modality and depth of tissue activation may influence clinical outcomes ( 20 ). The absence of significant improvement in FSFI scores may be attributed to multiple factors. First, the number of intervention sessions may have been insufficient to produce clinically meaningful effects, as previous studies on sexual rehabilitation suggest that more substantial functional gains typically emerge after 8 to 12 weeks of continuous intervention ( 21 ). Additionally, FSFI scores are influenced by psychosocial, hormonal, and relational variables—such as stress, menstrual cycle phase, and partner dynamics—which were not controlled in this study. The small sample size may also have contributed to increased interindividual variability and potential floor or ceiling effects. Together, these factors may explain why the observed reduction in pain did not translate into measurable changes in overall sexual function. The significant reduction in pain observed in this study remains clinically relevant, even in the absence of concurrent improvement in sexual function. Evidence suggests that pain is often the first component to respond to physiotherapeutic interventions and that its reduction may represent an initial step in disrupting the pain–anxiety–avoidance cycle commonly associated with chronic dyspareunia ( 22 ). In this context, pain relief may facilitate greater engagement in sexual activity and adherence to complementary therapeutic strategies. However, improvements in sexual function may require longer intervention periods or the integration of multimodal approaches. A non-significant trend toward improvement in self-esteem was observed following the intervention. This finding may be partially associated with pain reduction, as previous studies have demonstrated a relationship between decreased sexual pain and improvements in emotional well-being, body image, and self-perception ( 3 , 23 ). However, the small sample size may have limited the statistical power to detect significant changes in psychosocial outcomes. The heterogeneity of responses observed across outcomes suggests that individual factors play a significant role in the clinical course of dyspareunia. The multifactorial etiology of sexual pain—including conditions such as vestibulodynia, vaginismus, pelvic floor hypertonicity, hormonal influences, and psychosocial factors—may have contributed to the variability in treatment response. Additionally, differences between adolescent and adult participants, including sexual maturity, prior experiences, and body perception, may have influenced outcomes. These findings reinforce the importance of individualized therapeutic approaches that account for the complex interplay of physiological, emotional, and relational factors in the management of dyspareunia ( 17 ). From a physiological perspective, TENS modulates peripheral and central neuronal excitability, promoting analgesia through mechanisms described by the gate control theory and the activation of endogenous opioid pathways. On the other hand, electrical stimulation may contribute to neuromuscular activation of the pelvic floor, potentially influencing muscle function and local tissue dynamics. Previous studies have suggested that pelvic electrical stimulation may increase local blood flow and tissue oxygenation, which could be associated with improvements in pelvic function ( 24 ). In light of these mechanisms, the findings of this study suggest that TENS may have contributed to the observed reduction in perineal pain, even in a small sample. The improvement in pain, along with a non-significant increase in self-esteem, may indicate potential interactions between physiological modulation and psychosocial outcomes. These findings should be interpreted within the context of an exploratory case series. Although no improvement in sexual function was observed, the underlying mechanisms of neuromodulation and tissue response, together with existing literature, suggest that longer intervention periods or combined therapeutic approaches may be required to achieve clinically meaningful improvements in sexual function ( 18 – 20 ). The observed reduction in functional capacity, despite the improvement in pain, warrants careful interpretation. This finding may reflect interindividual variability or the influence of external factors not controlled in this study. As TENS primarily targets pain modulation rather than global physical function, changes in functional capacity may not occur concurrently with pain reduction. Previous studies indicate that the relationship between pelvic pain, mobility, and functional limitation is complex and influenced by multiple musculoskeletal, emotional, and behavioral factors ( 25 ). Regarding quality of life assessed by the SF-36, no significant improvements were observed across most domains. The reduction in the global pain domain does not necessarily conflict with the observed improvement in perineal pain, as the SF-36 is not specifically designed to assess sexual pain symptoms. Previous studies have highlighted that general health-related quality of life instruments may underestimate changes related to sexual pain conditions ( 9 ). The reduction in functional capacity further suggests that broader functional outcomes may not directly parallel improvements in localized pain, reinforcing the complexity of treatment responses in dyspareunia ( 3 , 4 , 9 , 16 , 25 ). This domain reflects general physical functioning rather than pelvic or sexual health–specific outcomes. Therefore, it may be influenced by factors not directly related to the intervention. TENS was well tolerated in this study, with no reported adverse effects during the intervention period. Its non-invasive nature, relatively low cost, and ease of application suggest potential applicability in outpatient and resource-limited settings. However, given the exploratory design and small sample size, these findings should be interpreted with caution. Further studies are required to confirm its safety profile and clinical effectiveness across different populations. This study has several limitations that should be acknowledged. The small sample size, absence of a control group, lack of randomization, and absence of follow-up limit the generalizability of the findings and preclude causal inference. Future studies should include larger samples, controlled designs, standardized stimulation parameters, and longer follow-up periods. Additionally, the use of outcome measures more specific to dyspareunia, as well as the control of hormonal, psychological, and behavioral variables, may improve the accuracy of clinical assessment. The incorporation of neurophysiological measures may also contribute to a better understanding of the central and peripheral mechanisms involved in sexual pain modulation. Conclusion This case series suggests that transcutaneous electrical nerve stimulation combined with pelvic floor muscle training may reduce pain in women with dyspareunia. However, no improvements were observed in sexual function or quality of life. These findings should be interpreted with caution due to the small sample size and study design limitations. Further controlled and longitudinal studies are required to confirm these results and clarify the clinical role of this intervention. Declarations Ethics approval and consent to participate This study was approved by the Research Ethics Committee of the Hospital das Clínicas, Federal University of Pernambuco (protocol no. 4.840.515). All participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant. Authors’ contributions Lara Freitas Matos Costa: Conceptualization, data collection, writing – original draft. Heloísa Cristina Barbosa de Santana and Rúbia Rayanne Souto Braz: Data collection, methodology. Agostinho de Sousa Machado Júnior: Supervision, review. Juliana Felipe da Silva Souza: Data analysis. Maria das Graças Rodrigues de Araujo: Supervision, review. Marcelo Renato Guerino: Conceptualization, data analysis, writing – original draft All authors read and approved the final manuscript. Acknowledgements Not applicable. References Orr NL, et al. Deep dyspareunia in endometriosis: role of the bladder and pelvic floor. J Sex Med. 2018;15(8):1158–66. 10.1016/j.jsxm.2018.06.004 . 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers invited by journal 13 Apr, 2026 Editor assigned by journal 08 Apr, 2026 Submission checks completed at journal 08 Apr, 2026 First submitted to journal 07 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Pernambuco","correspondingAuthor":false,"prefix":"","firstName":"Rúbia","middleName":"Rayanne Souto","lastName":"Braz","suffix":""},{"id":622958815,"identity":"95f30d21-31d9-4d56-9560-7dd9788f36de","order_by":5,"name":"Maria das Graças Rodrigues de Araujo","email":"","orcid":"","institution":"Federal University of Pernambuco","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"das Graças Rodrigues","lastName":"de Araujo","suffix":""},{"id":622958818,"identity":"d717157c-eddc-483f-bbce-7ddc63573674","order_by":6,"name":"Marcelo Renato Guerino","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYNCCAiidwMAgx8B8gIGBsYGQFgOEFmMGtgRStABBYgMhLbrtZx9++GBgwyAfkXzsw8MdNukbjvEefMC44x5OLWZn0o0lZxikMRjeSEuekXgmLXfDMb5kA8Yzxbi1HEhjY+YxOMxgOCPHmCGx7XDuhvs9ZhKMbQm4tZx/xsb8B6wl/zNIS7rBMR7zH3i13ADawgDUIi+RwwzSkgDUYsaAX8szZskegzQeA55nIIelGc4E+kUi8Qw+h6UxfvhRYSMn3578mPFnm408HzDEPnzcgVsLDPAYHECwwXFKGMg3IGsZBaNgFIyCUYAEAHBYUnhl+MxsAAAAAElFTkSuQmCC","orcid":"","institution":"Federal University of Pernambuco","correspondingAuthor":true,"prefix":"","firstName":"Marcelo","middleName":"Renato","lastName":"Guerino","suffix":""}],"badges":[],"createdAt":"2026-04-07 15:40:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9347276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9347276/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107484792,"identity":"0981f30e-f614-4347-af8c-9636a21bfc55","added_by":"auto","created_at":"2026-04-22 02:33:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32102,"visible":true,"origin":"","legend":"\u003cp\u003ePain intensity before and after intervention assessed by the Visual Analog Scale (VAS).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9347276/v1/d1f563d59718dbf8f42135fe.png"},{"id":107358554,"identity":"5640f693-3bae-477b-a50d-f8e8051f5573","added_by":"auto","created_at":"2026-04-20 17:36:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24341,"visible":true,"origin":"","legend":"\u003cp\u003eFemale sexual function scores before and after TENS intervention assessed by the Female Sexual Function Index (FSFI).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9347276/v1/1da1636392a6cf65aa417009.png"},{"id":107358552,"identity":"36f44116-a409-45b5-b80a-10553f52208b","added_by":"auto","created_at":"2026-04-20 17:36:10","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":129193,"visible":true,"origin":"","legend":"\u003cp\u003eSelf-esteem scores before and after TENS intervention assessed by the Rosenberg Self-Esteem Scale.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9347276/v1/2ee2b43d60ee394e7669d9a9.jpeg"},{"id":107487778,"identity":"b54b2f16-c3f4-4b7b-bb52-c459888eb63f","added_by":"auto","created_at":"2026-04-22 02:42:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":586914,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9347276/v1/449c9975-650e-4228-adf2-626cbf9a8b2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eClinical Effects of Pelvic Floor Transcutaneous Electrical Nerve Stimulation on Pain and Sexual Function in Dyspareunia: A Case Series\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSexual health is defined by the World Health Organization as a state of physical, emotional, mental, and social well-being in relation to sexuality, extending beyond the mere absence of disease or dysfunction. Within this framework, dyspareunia\u0026mdash;characterized by recurrent or persistent genital pain associated with sexual activity\u0026mdash;is a prevalent form of female sexual dysfunction with a multifactorial etiology involving biological, hormonal, and psychosocial components (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Clinically, dyspareunia may be classified as superficial, typically involving vulvar or introital pain, or deep, when pain is localized to pelvic structures such as the cervix, bladder, or lower pelvis (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe etiology of dyspareunia is complex and includes organic conditions such as endometriosis, pelvic infections, perineal trauma, and vaginal atrophy, as well as hormonal factors, particularly hypoestrogenism, and psychosocial contributors including anxiety, depression, and prior sexual trauma. Prevalence estimates vary widely depending on population and assessment methods, ranging from 1% to over 50%, reflecting both methodological heterogeneity and the multifactorial nature of the condition (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite its clinical relevance, there remains a lack of high-quality evidence regarding effective therapeutic interventions, particularly among adolescent and young adult populations.\u003c/p\u003e \u003cp\u003eDyspareunia has substantial implications for multiple domains of women\u0026rsquo;s health, including sexual function, psychological well-being, self-esteem, and interpersonal relationships. Pain during sexual activity may lead to avoidance behaviors, emotional distress, and significant impairment in quality of life, reinforcing the need for evidence-based, multidimensional therapeutic approaches (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePelvic floor physical therapy has emerged as a key component in the management of female sexual dysfunction, particularly through interventions targeting pelvic floor muscle function. These approaches aim to modulate pain, restore muscle coordination, and improve body awareness\u0026mdash;factors essential for sexual function recovery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Recent systematic reviews have demonstrated that pelvic floor muscle training is associated with improvements in pain, sexual function, and quality of life in women with sexual dysfunction (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTranscutaneous electrical nerve stimulation (TENS) has been proposed as a non-invasive therapeutic modality with potential benefits in pain modulation and neuromuscular function. Its analgesic effects are primarily explained by the gate control theory and the activation of endogenous opioid pathways, leading to reduced nociceptive transmission (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Additionally, TENS may enhance local blood flow, reduce muscle hypertonicity, and decrease tissue hypersensitivity, thereby contributing to pelvic floor rehabilitation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, despite its physiological plausibility and increasing clinical use, evidence regarding its effectiveness in dyspareunia remains limited and inconsistent, particularly in non-invasive transcutaneous applications.\u003c/p\u003e \u003cp\u003eGiven the clinical relevance of dyspareunia and the limited evidence regarding non-invasive therapeutic strategies, this study aimed to evaluate the clinical effects of TENS combined with pelvic floor muscle training on pain, sexual function, self-esteem, and quality of life in adolescent and adult women with dyspareunia. This investigation was designed as an exploratory case series to provide preliminary clinical insights into the role of TENS as a physical therapy modality in the management of sexual pain disorders.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This study was designed as an exploratory case series following CARE guidelines adapted for case series reporting. Ethical approval was obtained from the Research Ethics Committee of the Hospital das Cl\u0026iacute;nicas, Federal University of Pernambuco (protocol no. 4.840.515). The study was conducted at the Family Planning Clinic and the Gestational Trophoblastic Disease Clinic of the Hospital das Cl\u0026iacute;nicas of the Federal University of Pernambuco (HC-UFPE), and at the Electrothermophototherapy Laboratory (LETER) of the Physiotherapy Department. A convenience sample was recruited from outpatient clinical settings and institutional advertisements. Data collection was carried out between September 2024 and November 2025.\u003c/p\u003e \u003cp\u003eEligible participants were adolescent and adult women aged 13 to 40 years who reported pain occurring before, during, or after sexual intercourse and had a clinical diagnosis of dyspareunia of any etiology. Inclusion criteria comprised being sexually active and able to complete study assessments. Women with postpartum dyspareunia (within one year after delivery) were also included. For participants under 18 years of age, both informed assent and parental consent were obtained.\u003c/p\u003e \u003cp\u003eExclusion criteria included inability to understand or complete questionnaires, presence of active sexually transmitted infections, chronic vulvar disorders, prior oophorectomy or oophoroplasty, contraindications to electrical stimulation (including implanted electronic devices such as pacemakers), and current pregnancy.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003eParticipants underwent baseline clinical assessment followed by standardized evaluation using validated instruments. Pain intensity was assessed using the Visual Analog Scale (VAS). Sexual function was measured using the Female Sexual Function Index (FSFI), with scores below 26.55 indicating sexual dysfunction. Self-esteem was evaluated using the Rosenberg Self-Esteem Scale, and quality of life was assessed using the 36-Item Short Form Health Survey (SF-36). All instruments were previously validated for use in the Brazilian population (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003e Eligible participants provided written informed consent prior to participation. Baseline assessments included sociodemographic data and administration of all outcome measures. Participants meeting inclusion criteria proceeded to the intervention phase.\u003c/p\u003e\n\u003ch3\u003eIntervention Protocol\u003c/h3\u003e\n\u003cp\u003e Participants received an intervention consisting of pelvic floor muscle training combined with transcutaneous electrical nerve stimulation (TENS). Initially, participants were instructed on pelvic floor anatomy and muscle awareness. The exercise protocol consisted of three sets of ten sustained contractions, each held for six seconds, with 30-second rest intervals between sets.\u003c/p\u003e \u003cp\u003eFollowing the exercise session, TENS was applied transcutaneously to the perineal region using surface electrodes positioned bilaterally over the pubic area. Stimulation parameters were based on previous studies and included a frequency of 110 Hz and pulse duration of 80 \u0026micro;s. Intensity was adjusted individually to the maximum comfortable sensory threshold without inducing pain.\u003c/p\u003e \u003cp\u003eThe intervention was performed once weekly over five consecutive weeks. All participants were reassessed after completion of the intervention using the same outcome measures applied at baseline.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SigmaPlot version 12.0 (Systat Software Inc., San Jose, CA, USA). Data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for continuous variables. Given the small sample size and paired study design, within-subject comparisons were conducted between baseline and post-intervention measurements. The normality of data distribution was assessed using the Shapiro\u0026ndash;Wilk test.\u003c/p\u003e \u003cp\u003eFor variables with normal distribution, paired Student\u0026rsquo;s t-test was applied. For variables that did not meet normality assumptions, the non-parametric Wilcoxon signed-rank test was used. Mean differences and corresponding 95% confidence intervals (95% CI) were calculated when applicable. A two-tailed significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was adopted for all analyses.\u003c/p\u003e \u003cp\u003eDue to the exploratory nature of this case series and the limited sample size (n\u0026thinsp;=\u0026thinsp;7), the results should be interpreted with caution, and no adjustment for multiple comparisons was performed. Effect sizes were not calculated due to the exploratory nature of the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSeven women with dyspareunia were included in this case series and completed the intervention protocol. Primary outcomes were pain, sexual function, and self-esteem, while quality of life was considered a secondary outcome. All variables were assessed before and after the intervention.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Baseline characteristics of participants (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD/n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYellow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Partnered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic/Secondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher education (incomplete/complete)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly income, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1 minimum wage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 to 5 minimum wages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetropolitan region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or number of participants (percentage).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003ePercentages may not total 100% due to rounding.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean age of participants was 26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 years. Most participants were single (72%) and had incomplete higher education (58%), with a family income of up to five minimum wages (86%). Sociodemographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Reproductive characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReproductive and obstetric characteristics of participants (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of pregnancies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrenatal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, not applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocal prenatal care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoute of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVaginal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerineal trauma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as number of participants (percentage). Categories marked as \u0026ldquo;not\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eapplicable\u0026rdquo; refer to participants with no prior pregnancy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Reproductive and obstetric characteristics of participants (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003ePain intensity assessed by the Visual Analog Scale (VAS) showed a statistically significant reduction after the intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mean values decreased from 8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 at baseline to 4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 post-intervention. The mean difference was 4.0 points (95% CI: 0.5 to 7.5; p\u0026thinsp;=\u0026thinsp;0.031). Increased variability was observed in post-intervention scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSexual function, assessed using the Female Sexual Function Index (FSFI), showed a slight decrease from 22.09\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57 to 21.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85 after the intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.375). A reduction in variability was observed in post-intervention scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSelf-esteem scores increased from 13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 at baseline to 15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 post-intervention, without statistical significance (p\u0026thinsp;=\u0026thinsp;0.156) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A reduction in variability was observed after the intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eQuality of life assessed by the SF-36 showed a reduction in scores across all domains after the intervention. Most differences were not statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A significant reduction was observed only in the functional capacity domain, which decreased from 63.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4 to 55.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 (p\u0026thinsp;=\u0026thinsp;0.033). The pain domain decreased from 42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.7 to 38.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3, without statistical significance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of quality of life domains (SF-36) before and after intervention in women with dyspareunia (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Difference (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional Capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e63.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e55.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.9 (-14.9 to -0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.033*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimitations due to physical aspects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;38.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6 (-5.2 to 12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e38.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0 (-0.9 to 8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Health Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.0\u0026thinsp;\u0026plusmn;\u0026thinsp;24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e35.1\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.9 (-5.5 to 5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVitality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.0\u0026thinsp;\u0026plusmn;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0 (-8.6 to 18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Aspects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e41.1\u0026thinsp;\u0026plusmn;\u0026thinsp;22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9 (-3.9 to 21.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional Aspects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;26.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5 (-24.8 to 43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.625\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e35.4\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e32.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4 (-15.2 to 22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and mean difference (95% confidence interval). Statistical comparisons were performed using paired Student\u0026rsquo;s t-test or Wilcoxon signed-rank test, as appropriate. *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Comparison of quality of life domains (SF-36) before and after intervention in women with dyspareunia (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study demonstrated a statistically significant reduction in perineal pain following the intervention with TENS, accompanied by a non-significant trend toward improvement in self-esteem. In contrast, sexual function scores and certain domains of quality of life showed reductions, including a statistically significant decrease in functional capacity.\u003c/p\u003e \u003cp\u003eThe observed reduction in pain is consistent with previous evidence supporting the use of TENS in the management of dyspareunia and chronic pelvic pain (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, in contrast to prior studies reporting improvements in quality of life following electrotherapy, the present findings did not demonstrate similar benefits (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These discrepancies highlight the variability of clinical responses and reinforce the exploratory nature of the present study.\u003c/p\u003e \u003cp\u003eDespite evidence suggesting that electrical stimulation may improve sexual function, the present study did not demonstrate significant improvement in FSFI scores and observed a slight reduction following the intervention. This finding may be influenced by unmeasured variables known to affect sexual function, including hormonal fluctuations, psychological stress, and contextual factors, which are frequently associated with dyspareunia and may modulate treatment response (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, studies employing intravaginal electrical stimulation have reported more consistent improvements in sexual function, suggesting that differences in stimulation modality and depth of tissue activation may influence clinical outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe absence of significant improvement in FSFI scores may be attributed to multiple factors. First, the number of intervention sessions may have been insufficient to produce clinically meaningful effects, as previous studies on sexual rehabilitation suggest that more substantial functional gains typically emerge after 8 to 12 weeks of continuous intervention (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, FSFI scores are influenced by psychosocial, hormonal, and relational variables\u0026mdash;such as stress, menstrual cycle phase, and partner dynamics\u0026mdash;which were not controlled in this study. The small sample size may also have contributed to increased interindividual variability and potential floor or ceiling effects. Together, these factors may explain why the observed reduction in pain did not translate into measurable changes in overall sexual function.\u003c/p\u003e \u003cp\u003eThe significant reduction in pain observed in this study remains clinically relevant, even in the absence of concurrent improvement in sexual function. Evidence suggests that pain is often the first component to respond to physiotherapeutic interventions and that its reduction may represent an initial step in disrupting the pain\u0026ndash;anxiety\u0026ndash;avoidance cycle commonly associated with chronic dyspareunia (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this context, pain relief may facilitate greater engagement in sexual activity and adherence to complementary therapeutic strategies. However, improvements in sexual function may require longer intervention periods or the integration of multimodal approaches.\u003c/p\u003e \u003cp\u003eA non-significant trend toward improvement in self-esteem was observed following the intervention. This finding may be partially associated with pain reduction, as previous studies have demonstrated a relationship between decreased sexual pain and improvements in emotional well-being, body image, and self-perception (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, the small sample size may have limited the statistical power to detect significant changes in psychosocial outcomes.\u003c/p\u003e \u003cp\u003eThe heterogeneity of responses observed across outcomes suggests that individual factors play a significant role in the clinical course of dyspareunia. The multifactorial etiology of sexual pain\u0026mdash;including conditions such as vestibulodynia, vaginismus, pelvic floor hypertonicity, hormonal influences, and psychosocial factors\u0026mdash;may have contributed to the variability in treatment response.\u003c/p\u003e \u003cp\u003eAdditionally, differences between adolescent and adult participants, including sexual maturity, prior experiences, and body perception, may have influenced outcomes. These findings reinforce the importance of individualized therapeutic approaches that account for the complex interplay of physiological, emotional, and relational factors in the management of dyspareunia (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a physiological perspective, TENS modulates peripheral and central neuronal excitability, promoting analgesia through mechanisms described by the gate control theory and the activation of endogenous opioid pathways.\u003c/p\u003e \u003cp\u003eOn the other hand, electrical stimulation may contribute to neuromuscular activation of the pelvic floor, potentially influencing muscle function and local tissue dynamics. Previous studies have suggested that pelvic electrical stimulation may increase local blood flow and tissue oxygenation, which could be associated with improvements in pelvic function (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn light of these mechanisms, the findings of this study suggest that TENS may have contributed to the observed reduction in perineal pain, even in a small sample. The improvement in pain, along with a non-significant increase in self-esteem, may indicate potential interactions between physiological modulation and psychosocial outcomes.\u003c/p\u003e \u003cp\u003eThese findings should be interpreted within the context of an exploratory case series. Although no improvement in sexual function was observed, the underlying mechanisms of neuromodulation and tissue response, together with existing literature, suggest that longer intervention periods or combined therapeutic approaches may be required to achieve clinically meaningful improvements in sexual function (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The observed reduction in functional capacity, despite the improvement in pain, warrants careful interpretation. This finding may reflect interindividual variability or the influence of external factors not controlled in this study.\u003c/p\u003e \u003cp\u003eAs TENS primarily targets pain modulation rather than global physical function, changes in functional capacity may not occur concurrently with pain reduction. Previous studies indicate that the relationship between pelvic pain, mobility, and functional limitation is complex and influenced by multiple musculoskeletal, emotional, and behavioral factors (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding quality of life assessed by the SF-36, no significant improvements were observed across most domains. The reduction in the global pain domain does not necessarily conflict with the observed improvement in perineal pain, as the SF-36 is not specifically designed to assess sexual pain symptoms. Previous studies have highlighted that general health-related quality of life instruments may underestimate changes related to sexual pain conditions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The reduction in functional capacity further suggests that broader functional outcomes may not directly parallel improvements in localized pain, reinforcing the complexity of treatment responses in dyspareunia (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This domain reflects general physical functioning rather than pelvic or sexual health\u0026ndash;specific outcomes. Therefore, it may be influenced by factors not directly related to the intervention.\u003c/p\u003e \u003cp\u003eTENS was well tolerated in this study, with no reported adverse effects during the intervention period. Its non-invasive nature, relatively low cost, and ease of application suggest potential applicability in outpatient and resource-limited settings. However, given the exploratory design and small sample size, these findings should be interpreted with caution. Further studies are required to confirm its safety profile and clinical effectiveness across different populations.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. The small sample size, absence of a control group, lack of randomization, and absence of follow-up limit the generalizability of the findings and preclude causal inference.\u003c/p\u003e \u003cp\u003eFuture studies should include larger samples, controlled designs, standardized stimulation parameters, and longer follow-up periods. Additionally, the use of outcome measures more specific to dyspareunia, as well as the control of hormonal, psychological, and behavioral variables, may improve the accuracy of clinical assessment. The incorporation of neurophysiological measures may also contribute to a better understanding of the central and peripheral mechanisms involved in sexual pain modulation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case series suggests that transcutaneous electrical nerve stimulation combined with pelvic floor muscle training may reduce pain in women with dyspareunia. However, no improvements were observed in sexual function or quality of life. These findings should be interpreted with caution due to the small sample size and study design limitations. Further controlled and longitudinal studies are required to confirm these results and clarify the clinical role of this intervention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee of the Hospital das Clínicas, Federal University of Pernambuco (protocol no. 4.840.515). All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLara Freitas Matos Costa: Conceptualization, data collection, writing – original draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHeloísa Cristina Barbosa de Santana and Rúbia Rayanne Souto Braz: Data collection, methodology.\u003c/p\u003e\n\u003cp\u003eAgostinho de Sousa Machado Júnior: Supervision, review.\u003c/p\u003e\n\u003cp\u003eJuliana Felipe da Silva Souza: Data analysis.\u003c/p\u003e\n\u003cp\u003eMaria das Graças Rodrigues de Araujo: Supervision, review.\u003c/p\u003e\n\u003cp\u003eMarcelo Renato Guerino: Conceptualization, data analysis, writing – original draft\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrr NL, et al. 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J Sex Med. 2024;21(2):145\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jsxmed/qdad169\u003c/span\u003e\u003cspan address=\"10.1093/jsxmed/qdad169\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"dyspareunia, transcutaneous electrical nerve stimulation, pelvic floor, sexual dysfunction, physical therapy modalities","lastPublishedDoi":"10.21203/rs.3.rs-9347276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9347276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDyspareunia is characterized by pain occurring before, during, or after sexual intercourse and has a multifactorial etiology involving biological, hormonal, and psychosocial factors. It can significantly impair quality of life and sexual well-being.\u003c/p\u003e\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the effects of transcutaneous electrical nerve stimulation (TENS) combined with pelvic floor muscle training on pain, sexual function, self-esteem, and quality of life in women with dyspareunia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis case series included seven women with dyspareunia assessed before and after a five-session intervention protocol. The intervention consisted of TENS combined with pelvic floor muscle training. Outcomes included pain (Visual Analog Scale), sexual function (Female Sexual Function Index), self-esteem (Rosenberg Self-Esteem Scale), and quality of life (SF-36).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA statistically significant reduction in pain was observed (p\u0026thinsp;=\u0026thinsp;0.031). No significant improvements were found in sexual function or quality of life.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTENS combined with pelvic floor muscle training may reduce pain in women with dyspareunia; however, no improvements were observed in sexual function or quality of life. Further controlled studies are required.\u003c/p\u003e","manuscriptTitle":"Clinical Effects of Pelvic Floor Transcutaneous Electrical Nerve Stimulation on Pain and Sexual Function in Dyspareunia: A Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-20 17:36:06","doi":"10.21203/rs.3.rs-9347276/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-23T19:27:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301282630675201079515844152637316408262","date":"2026-04-14T11:57:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-13T11:38:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-08T23:38:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-08T23:37:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-04-07T15:27:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a9ff897-28a5-4a3c-9d86-a9303c23b5f2","owner":[],"postedDate":"April 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T17:36:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-20 17:36:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9347276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9347276","identity":"rs-9347276","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}