Letter to the Editor on "Chronic abdominal pain and dyspareunia in endometriosis: pain therapy with a nerve and muscle stimulation device with biofeedback function"

We read with great interest the study by Braml et al., which examined a home-based intravaginal electromyographic biofeedback and electrical stimulation program in women with endometriosis-associated chronic pelvic pain and pelvic floor dysfunction.1 The study draws attention to an important clinical issue: persistent pain and dyspareunia in endometriosis may not be explained solely by endometriotic lesions, but may also involve pelvic floor dysfunction and altered pain processing. The reported improvement in pelvic floor pain and dyspareunia after 12 weeks of treatment is therefore of particular interest. At the same time, the persistence of elevated Central Sensitization Inventory scores despite symptomatic improvement highlights the complexity of this clinical phenotype and suggests that local pelvic floor mechanisms and central sensitization may coexist. From a urological perspective, one aspect of this phenotype deserves further attention: the lower urinary tract. In the study, urinary involvement was assessed mainly through dysuria, while the broader spectrum of lower urinary tract symptoms (LUTS) was not systematically characterized.1 Dysuria is clinically relevant in endometriosis, but it reflects only one dimension of urinary involvement. Current guidelines classify female LUTS into storage, voiding, and post-micturition symptoms, encompassing complaints such as urgency, frequency, nocturia, hesitancy, intermittency, slow stream, straining, and incomplete bladder emptying.2 This distinction may be particularly relevant in endometriosis, where bladder pain syndrome/interstitial cystitis may coexist with pelvic pain and dyspareunia.3 Women with pelvic floor overactivity or impaired relaxation may therefore present with urinary symptoms extending well beyond dysuria. From a functional perspective, alterations in pelvic floor muscle tone, coordination, and relaxation may manifest across several domains, including pain, sexual function, and lower urinary tract function. A broader LUTS assessment could therefore have complemented the pain-focused evaluation and provided a more complete characterization of the pelvic floor phenotype.