Effect of Respiratory Exercises With Pelvic Floor Rehab on Dyspareunia & Autonomic Function in Women

Background and Aim:

Dyspareunia, or pain during sexual intercourse, is a common component of female sexual dysfunction and may have multifactorial origins, including musculoskeletal and autonomic factors. While pelvic floor rehabilitation is an established treatment approach for musculoskeletal dyspareunia, it may not sufficiently address the autonomic dysregulation commonly observed in chronic pain conditions. The aim of this study is to investigate the effects of adding diaphragmatic breathing exercises and diaphragm manual therapy to standard pelvic floor rehabilitation on pain severity, pelvic floor function, and autonomic nervous system regulation in women diagnosed with musculoskeletal-origin dyspareunia.

Methods:

This randomized controlled clinical trial will be conducted between September 1, 2025, and December 1, 2025, at the Kurbaa Training and Consultation Center in Istanbul. A total of 45 participants aged 18-45 years who meet the inclusion criteria will be randomly assigned into three equal groups (n = 15):

Group I: Pelvic floor rehabilitation only

Group II: Pelvic floor rehabilitation + diaphragmatic breathing exercises

Group III: Pelvic floor rehabilitation + diaphragmatic breathing exercises + diaphragm manual therapy

Interventions will be administered once per week for 8 weeks. Pre- and post-intervention assessments will include pain intensity (Visual Analog Scale), pelvic floor muscle function (ultrasonography), sexual function (Female Sexual Function Index), anxiety level (Beck Anxiety Inventory), and autonomic regulation (Heart Rate Variability using Elite HRV). Statistical analyses will be performed using SPSS with significance set at p < 0.05.

Expected Contribution:

This study is expected to contribute to the development of more comprehensive treatment protocols for dyspareunia by integrating physical and neurophysiological rehabilitation components. It may also provide evidence supporting the role of autonomic regulation in improving treatment outcomes for female sexual pain disorders.

Inclusion criteria

Female participants aged between 18 and 45 years

Experiencing dyspareunia of musculoskeletal origin for at least 6 months

In a stable sexual relationship and sexually active

Willing and able to attend weekly treatment sessions for 8 weeks

Able to provide informed consent

No pelvic surgery within the last 6 months

Normal cognitive function and ability to follow instructions

Baseline FSFI score indicating sexual dysfunction (e.g., ≤ 26.55)

Exclusion criteria

• Presence of neurological, gynecological, or urological pathologies causing pelvic pain (e.g., endometriosis, pelvic inflammatory disease)

Pregnancy or postpartum period within the last 6 months

Diagnosed psychiatric disorders (e.g., major depression, psychosis)

Use of medications that affect autonomic nervous system function (e.g., beta-blockers, antidepressants)

History of pelvic radiation, cancer, or pelvic trauma

Participation in other rehabilitation or psychotherapy programs during the study period

Inability to tolerate manual therapy or perform breathing exercises

BMI > 35, which may interfere with ultrasonographic assessment

Non-compliance risk, such as irregular attendance or language barriers