Abstract
Gender-affirming genital reconstruction surgeries (GAGRS) are essential procedures aimed at aligning transgender individuals’ physical characteristics with their gender identity. While these surgeries have been shown to improve psychological well-being and overall mental health, they often come with challenges, particularly in preserving sexual sensation and function. Despite advancements in surgical strategies, postoperative sexual rehabilitation remains an underexplored aspect of gender-affirming care. Emerging evidence suggests that transcutaneous electrical nerve stimulation (TENS) may offer a promising noninvasive approach to enhancing sexual function. This paper explores the role of TENS in sexual rehabilitation following GAGRS, emphasizing the need for a more comprehensive approach that goes beyond anatomical reconstruction.
Plain language summary
Gender-affirming genital reconstruction surgery can significantly improve mental health, but often leads to changes in genital sensation, affecting sexual function and quality of life. Despite advances in surgical techniques, strategies for restoring sexual sensation remain limited. This paper explores
Keywords
Introduction
Gender-affirming genital reconstruction surgeries (GAGRS) refer to the surgical procedures that are performed as part of gender-affirming health care to align the physical characteristics of transgender individuals with their intrinsic gender identity. These surgeries are aimed at reconstructing genitalia to create functional and aesthetically congruent genital structures while also preserving sexual sensation and function. Several studies have supported the fact that gender-affirming interventions can improve psychological well-being and overall mental health in this population.1,2
In GAGRS, reconstructed genitals are prone to reduced sensitivity or loss of sensation, both tactile and erogenous, which can severely affect the patients’ quality of life and the overall quality of care. Maintaining the sensitivity is directly influenced by several surgical factors, including nerve grafting techniques, neurotization, the post-surgical healing process, and rehabilitative modalities. Importantly, it also varies among individuals, as some patients may experience heightened sensitivity, while others may face reduced sensation or altered sensory experiences. 3
The most common procedure in male-to-female (MTF) GAGRS is vaginoplasty. This procedure involves creating a vaginal canal, or neovagina, using either penile or intestinal tissue. In addition, the neoclitoris can be constructed from the glans of the penis in a procedure known as clitoroplasty. Some patients may opt for vulvoplasty, which focuses solely on creating external genitalia without forming a vaginal canal. In female-to-male reassignment surgery, individuals may undergo either metoidioplasty or phalloplasty to create male-typical genitalia. These procedures can also include options for urethral lengthening and scrotoplasty.4–7
Given the complexity of GAGRS and the significant alterations the individuals go through, sexual rehabilitation plays a crucial role in restoring sexual function. However, the lack of focus on this aspect reveals a fundamental flaw in gender-affirming and transgender care. It also highlights the need to investigate this component more thoroughly, rather than just emphasizing the anatomical and functional outcomes of the surgery.
Transcutaneous electrical nerve stimulation (TENS) is a noninvasive therapeutic and rehabilitative modality, mostly used for pain management and neurorehabilitation purposes.8–12 It has also shown promise in promoting sexual health; for instance, a randomized controlled trial by Murina et al. 13 assessed the applicability of TENS in treating vestibulodynia and found that it not only significantly reduced pain but also improved sexual function. Similarly, Zimmerman et al. 14 used TENS to stimulate the dorsal genital nerve and posterior tibial nerve in nine women experiencing sexual dysfunction symptoms. Their results showed an increased Female Sexual Function Index score, particularly in the subdomains of lubrication, arousal, and orgasm. More recently, Giannopapas et al. 15 conducted a pilot randomized controlled trial using transcutaneous tibial nerve stimulation (TTNS) in 40 patients with multiple sclerosis and primary sexual dysfunction. Patients were randomized to receive either TTNS or sham stimulation three times over 2 months. The TTNS group exhibited significant improvements in erectile function (in men), vaginal lubrication (in women), orgasm quality, sexual satisfaction, and desire. Improvements were also observed in bladder-related symptoms, which may secondarily impair sexual function.
Furthermore, Waldinger et al. 16 reported the successful use of TENS in two women with restless genital syndrome, where the treatment resulted in significant improvements in symptoms such as spontaneous orgasms and restless genital sensations. In both cases, TENS applied to the relevant genital dermatomes led to a reduction in complaints, with one participant experiencing a 90% reduction in symptoms after 2 months of treatment.
These findings not only highlight the neuromodulatory potential of peripheral nerve stimulation, especially TENS, in managing neurogenic sexual dysfunction but also align with a growing body of evidence supporting this technique as a therapeutic approach for sexual rehabilitation across diverse patient populations. In this paper, it was hypothesized that TENS could represent a valuable technique in enhancing sexual function and satisfaction for transgender individuals, potentially offering a noninvasive and safe option for sexual rehabilitation in this population. By exploring its application in this unique population, the study aims to contribute to the growing body of research on sexual neurorehabilitation and support the development of inclusive, patient-centered interventions that address post-surgical sexual health outcomes.
Surgical strategies for preserving sexual function during GAGRS
During the GAGRS, nerve sparing is one of the most crucial steps for maintaining and regaining sexual function and the erotic sensation. It is particularly challenging because it involves delicate surgical work around a highly sensitive tissue. 17
In phalloplasty, as the neophallus is created from tissues that naturally lack nerve endings, nerve sparing is particularly challenging. Surgeons perform microsurgical nerve anastomosis, connecting nerves from the clitoral dorsal nerve to nerves within the grafted tissue, to overcome this challenge. 18 While full sensation may not always be achieved, this technique offers one of the best approaches for the potential sensory return.
In a related but distinct context, Van Lierop et al. 19 investigated nerve transfer to restore genital sensation in patients with spinal cord lesions. Their study involved transferring the ilioinguinal nerve to the dorsal clitoral nerve in women with absent genital sensation below the level of L1. To evaluate sensory outcomes, the authors conducted neurological assessments using simple sensory tests for touch (pointed vs blunt) and temperature (warm at 37°C vs cold at 4°C), applied bilaterally at the groin, inner thigh, labium majus, labium minus, clitoral hood, clitoris, and introitus. In addition to documenting the presence or absence of sensation, they recorded the subjective location where sensation was perceived—whether at the site of stimulation or referred elsewhere, such as the groin. These assessments were complemented by psychosexological interviews that explored the presence and quality of sensation (tactile or erogenous, pleasant or painful), as well as changes in arousal, orgasm, lubrication, and bladder function. According to their results, three of the four patients developed unilateral sensation in the clitoris and labia minora within 3–4 months postoperatively, which evolved further by 18 months. One patient reported the ability to achieve orgasm, and another showed unexpected improvement in bladder function, suggesting potential secondary benefits of the nerve transfer.
While phalloplasty literature increasingly addresses nerve coaptation, vaginoplasty techniques also rely heavily on precise nerve preservation, though this is less frequently discussed in detail. In cases where the nerve is successfully preserved and reattached to surrounding tissue or the clitoral neophallus, individuals can experience gradual recovery of sensitivity over time.
First introduced by Gillies and Millard in 1957, the penile inversion vaginoplasty (PIV) technique, in which the penile skin is inverted and advanced into the neo-vaginal space, is the most performed procedure in MTF GAGRS. This method was refined later by Dr. Georges Burou.20,21 Even with the current optimized version of this technique, the nerve healing process is still complex, unpredictable, and multifactorial. Variables such as the type of surgical technique, the extent of nerve sparing, individual healing capacity, and the presence of any post-operative complications can influence the regeneration of sensory nerves.
It is also noteworthy that both surgical procedures—phalloplasty and vaginoplasty—present different levels of complexity in terms of restoring erogenous sensation. Although vaginoplasty is commonly perceived to yield superior sexual outcomes, this assumption is not well-supported by robust clinical studies. Hence, there is a need to explore rehabilitative strategies such as TENS in both surgical contexts.
Strategies for restoring sexual function after GAGRS: Rehabilitative approaches
Beyond surgical techniques, postoperative nerve regeneration is an ongoing and often unpredictable process that may span months to years. 22 While surgical nerve sparing is essential for creating functional anatomy, the restoration of sexual function, particularly erotic sensation, may require additional interventions. Rehabilitation modalities, such as hormonal and physical therapy, can be necessary to optimize sensory function.
Aside from the well-documented physiological and psychological outcomes,23–25 hormone therapy can also subtly influence nerve regeneration after GAGRS. To begin with, estrogen has been shown to increase blood flow to genital tissues, potentially enhancing sensation and promoting healing in the neovagina and neoclitoral region following PIV. 24 Similarly, testosterone therapy plays a crucial role in supporting nerve regeneration. 26 In transmasculine individuals, especially those who have undergone procedures like metoidioplasty and phalloplasty, testosterone induces the enlargement of the clitoris, which, when combined with surgical techniques, contributes to a functional phallus with preserved erogenous sensation. 27 In the case of phalloplasty, testosterone pre-treatment helps develop the appropriate tissue for constructing a functional and aesthetically congruent phallus. 24
Pelvic floor rehabilitation plays an important role by enhancing the blood flow and strengthening pelvic floor muscles.28,29 In transfeminine individuals, it may promote nerve regeneration and improvement of blood circulation, which can be beneficial for sensation recovery, while also reducing the risk of edema and supporting the health of reconstructed tissues. For transmasculine individuals, undergoing metoidioplasty, pelvic floor rehabilitation can assist in enhancing clitoral or neophallus sensitivity. Following phalloplasty, pelvic floor rehabilitation helps ensure that the pelvic floor muscles can properly support the neophallus.
Furthermore, specialized therapy, focusing on erotic sensory re-education, may be beneficial in some individuals. Peters et al. 30 introduced a novel neurosensory re-education protocol, developed over four phases, which focused on optimizing sensory function after phalloplasty. This protocol consisted of exercises targeting peripheral nerve contributions and central nervous system re-education, incorporating visualization, tactile stimulation, and sexual/erogenous stimulation to help individuals develop erogenous sensations in the neophallus.
TENS: Mechanism and clinical applications
TENS is a noninvasive modality that delivers low-voltage electrical currents to stimulate nerves through the skin. 31 It is widely used for pain management and rehabilitation, particularly in cases of nerve injury, chronic pain, or sensory dysfunction. 11 Beyond its analgesic effects, TENS enhances neural activity and facilitates the restoration of damaged neural pathways through several complex processes.
First, when electrical impulses are delivered through the skin, they mimic natural action potentials, triggering voltage-gated ion channels to open. This results in the depolarization of neurons and the propagation of action potentials along the nerves. 31 TENS also stimulates the release of neurotrophic factors essential for neural health. These include nerve growth factor, brain-derived neurotrophic factor, and glial-derived neurotrophic factor. 32 These factors are essential for the survival and differentiation of neurons, thereby promoting axonal regeneration and enhancing synaptic plasticity, both of which are vital for sensory recovery. 33
In addition to this, TENS can increase calcium influx, which activates protein kinases such as Mitogen-Activated Protein Kinase (MAPK) and Protein Kinase C (PKC). This can initiate signaling cascades that regulate gene expression associated with cell regeneration.34,35
A study by Goganau et al. 36 explored how electrical stimulation (ES) can enhance axonal regeneration. They used KCl-induced depolarization and in vivo ES in sensory neuron cultures and spinal cord injury models. They found that short-term ES increased neurite growth, and even longer durations of ES enhanced growth if there was a sufficient delay between stimulation and growth measurements. Specifically, after in vivo ES of the intact sciatic nerve, sensory neurons exhibited a twofold increase in neurite length 1 week later compared to control animals, underscoring the regenerative potential of ES. In addition, longer or repeated ES (up to 7 days) continued to increase growth but provided diminishing returns beyond a certain point. According to their findings, while ES did not result in full sensory recovery, it has time-dependent influences on the regenerative capacity of sensory neurons and could enhance axonal regeneration, especially when combined with other therapeutic approaches.
Moreover, TENS has been shown to promote remyelination, which is essential for efficient signal transmission through the axon after the nerve injury. TENS stimulates the activity of oligodendrocytes in the central nervous system and Schwann cells in the peripheral nervous system, encouraging the regeneration of myelin sheaths and facilitating signal conduction. 37
Finally, by reducing the release of pro-inflammatory cytokines and modulating the activity of microglial and astrocyte cells, TENS minimizes secondary damage to neurons. It simultaneously promotes the release of anti-inflammatory cytokines, thereby creating a more favorable environment for nerve regeneration. 38
TENS in sexual function restoration after gender-affirming surgery
Transgender individuals who have undergone GAGRS often experience altered genital sensation and sexual dysfunction, commonly manifesting as anorgasmia or hypoorgasmia, all of which can significantly affect patients’ quality of life and overall well-being. Given its established mechanisms in rehabilitative medicine as discussed, TENS presents a promising, noninvasive approach for enhancing postoperative outcomes, particularly in relation to sexual function, in various clinical settings. By facilitating sensory reintegration through multiple pathways, TENS theoretically supports sexual recovery after GAGRS.
An important consideration in applying TENS is the choice of stimulation site, as different anatomical targets may engage distinct neurophysiological pathways. Among those explored in previous studies, the dorsal genital nerve and posterior tibial nerve have shown the most promise for sexual neurorehabilitation. The dorsal genital nerve, often coapted during clitoroplasty and phalloplasty, is directly involved in conveying erogenous sensation and has been effectively targeted in small-scale studies to improve arousal, lubrication, and orgasm. The posterior tibial nerve, which shares spinal roots with pelvic and genital innervation, modulates sacral plexus activity and has demonstrated benefits in both neurogenic and non-neurogenic sexual dysfunctions. By contrast, while paravertebral and sacral dermatome stimulation may have theoretical merit, clinical evidence supporting their role in sexual rehabilitation remains limited. Table 1 summarizes the proposed sites of TENS application for sexual function restoration after GAGRS.
Suggested TENS application sites for sexual function restoration after GAGRS.
GAGRS, gender-affirming genital reconstruction surgeries; TENS, transcutaneous electrical nerve stimulation.
Beyond its physiological rationale, TENS also offers several practical advantages that make it a highly appealing modality in clinical settings. It is a relatively low-cost and low-maintenance modality that generally does not require specialized infrastructure or prolonged clinical visits. 39 Once adequately trained, patients can use TENS independently at home, 40 reducing the need for frequent medical visits and associated costs.39,41 The devices are designed to be user-friendly, with adjustable settings for pulse width, intensity, and frequency, allowing users to tailor the treatment to their comfort level, 42 thereby promoting autonomy and adherence to therapy.
Its noninvasive nature minimizes the risk of complications, such as infection or nerve injury, making it particularly suitable for individuals in the postoperative healing phase. 43 The therapy is also well-tolerated, with minimal reported side effects—typically limited to mild skin irritation at the site of electrode application.
By contrast, other neuromodulation techniques, such as implanted nerve stimulators or biofeedback-assisted pelvic floor therapy, often require clinic-based supervision, greater financial investment, and more intensive practitioner involvement. These barriers can limit accessibility, especially for transgender individuals who may already face healthcare inequities. 44 Furthermore, TENS is more cost-effective compared to long-term pharmacologic methods with fewer systemic side effects.
Conclusion
TENS’s portability, safety, and user-friendly application position it as an ideal candidate for broader implementation in personalized post-surgical care protocols. Future applications of TENS in post-GAGRS care should consider site-specific protocols tailored to each patient’s surgical anatomy and therapeutic goals. In addition, future research should begin with preclinical models to investigate the neurophysiological effects of TENS on sensory nerve regeneration, cortical reorganization, and neuromodulation in the context of genital sensation. These foundational studies will provide essential insights into the underlying mechanisms before advancing to clinical trials. Subsequent trials should aim to define optimal TENS parameters—such as frequency, intensity, duration, and timing of initiation post-surgery. Longitudinal outcome measures will be crucial in substantiating the effectiveness of TENS as a rehabilitative intervention in gender-affirming surgical care.
