Introduction
Multiple sclerosis (MS) is a prevalent neurodegenerative disease characterized by demyelination in the central nervous system (CNS), impacting around 2.8 million individuals globally. The disease manifests through a wide range of clinical phenotypes, driven primarily by neuroinflammatory and degenerative mechanisms. 1 Over time, many patients develop motor impairments such as spasticity, fatigue, and balance issues, as well as non-motor symptoms like pain, bladder and bowel dysfunction, and frequently, sexual dysfunction (SD). SD in MS refers to difficulties in sexual performance, which may include reduced libido, erectile dysfunction, vaginal dryness, challenges with arousal, and trouble achieving orgasm. 2 These symptoms often lead to long-term urogenital complications. Studies suggest that 50%-90% of men and 40%-80% of women with MS will experience some form of SD during their lifetime. 3
Conventionally, pharmacological interventions have been the first-line treatment option for these dysfunctions. However, non-pharmacological rehabilitation approaches have emerged as promising alternatives, potentially offering fewer side effects and cost-effectiveness. 4 Despite their potential benefits, the effectiveness of these interventions in managing SDs in patients with MS remains unclear and under-researched, leaving clinicians and researchers without a thorough understanding of the available evidence.
This is because most of the current systematic reviews have largely addressed and reviewed motor impairments such as spasticity and gait, with only a limited number of review studies specifically targeting SD. For example, there are three systematic review studies investigating the effectiveness of non-pharmacological rehabilitation interventions for SD, 1 , 5 , 6 which are descriptive reviews, have no meta-analysis data, lack many outcome measures regarding QOL or daily activities, and miss many non-pharmacological interventions since they were primarily focused on specific treatment options only. On the other hand, there is a single meta-analysis review 7 ; however, it was a 2021 review, thus it identified fewer related RCTs, focused on overall interventions (medical and nonmedical) for sexual function and dysfunction with no attention to sexual satisfaction, and missed other range of interventions, such as virtual reality, inter-vaginal-based electrical stimulation, and autogenic therapy.
Therefore, to provide a clear and current answer for patients and clinicians, this research set out to comprehensively review and statistically combine all the available evidence. This study was designed to answer a central question: Do non-pharmacological rehabilitation interventions significantly improve sexual function and satisfaction in patients with MS?
Consequently, this research aims to systematically evaluate and meta-analyze available evidence to comprehensively examine and summarize the efficacy of non-pharmacological rehabilitation approaches in addressing SD and satisfaction in individuals with MS.
Methods
A systematic review and meta-analysis of all available clinical trials have investigated the impact and the therapeutic effect of any non-pharmacological interventions in the management of SD and satisfaction in patients with MS. Our study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation. 8 This study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024546632).
Search strategies
A thorough search was conducted across PubMed, Science Direct, CINAHL, and Cochrane databases, covering records from database inception until December 2024. Additionally, a manual search was carried out by examining the reference lists of the included studies to identify relevant literature from other sources. Diverse search strategies were employed, utilizing the maximum allowable Boolean operators specific to each database. Further details regarding the search strategies on each database are provided in the appendix.
Study selection
Two independent researchers (A.A. and H.H.) reviewed the titles/abstracts of the studies based on the eligibility criteria. The title/abstract screening and full-text screening process focused on the eligibility criteria. Suppose there is uncertainty between the two researchers about whether the study should be included or excluded. In that case, the reasons are discussed directly between the two researchers, and (M.E.), a third researcher, was involved in the discussion to arbitrate.
Eligibility criteria
The inclusion criteria were organized following the PICO framework.
Participants (P): Adult patients with MS. Interventions (I): Any non-pharmacological and rehabilitation interventions. Comparators (C): The control group received a conventional or sham intervention. Outcomes (O): The primary outcome focused on improvements in SDs, while the secondary outcome centered on enhancements in quality of life (QOL).
Studies that meet any of the following criteria are excluded: (1) The study is not a randomized controlled trial (reviews, case studies); (2) studies published in the abstract only, dissertations, or in books; (3) studies include patients with other neurological diseases than MS; and (4) studies published in a language other than English.
Risk of bias
The risk of bias in the studies included was evaluated using the revised Cochrane ROB 2.0 risk of bias tool for RCT studies (22nd version, 2019). As for the crossover experiments, a version was used for the crossover trials (8th version, 2020). The following domains of ROB 2.0 were assessed: (1) randomization process; (2) deviations from intended interventions, in addition to the blindness of participants and staff; (3) missing outcome data; (4) measurement of the outcome, in addition to blinding of the assessor; and (5) selection of the reported result. Additionally, a special domain for crossover trials: (S) bias arising from period and carryover effects. 9
Data extraction
The extracted data includes (1) Demographic characteristics (sample size, patient age, and gender), (2) MS duration, and MS types (relapsing–remitting MS (RR), primary progressive MS (PP), secondary progressive MS (SP), and progressive relapsing MS (PR)), (3) the intervention used in Experimental and Control groups, (4) the Expanded Disability Status Scale (EDSS) score, (5) the protocol used in each group such as the number and duration of sessions/evaluations schedule, and (6) outcome measures used and main results at each time point. When the original data was unclear or insufficient (if available), the researcher (A.A.) took steps to clarify or address the gaps. This may have involved contacting the authors of the studies for additional details, reviewing supplementary materials, or applying predefined criteria to interpret the data accurately.
Statistical analysis
A narrative synthesis of patient characteristics was presented, utilizing counts and percentages for categorical variables and mean ± standard deviation (SD) for continuous variables. A qualitative synthesis of findings from the included studies was provided. A synthesis was conducted to highlight the key characteristics of the studies, interventions, outcomes, and results. Studies were compared based on study design, participant characteristics, intervention details, and outcomes assessed. Additionally, studies with similar interventions, comparators, and outcome measures were considered for inclusion in the meta-analysis. Standardized mean difference (SMD) for continuous outcomes (eg, satisfaction level, leakage time, etc.) was calculated by the difference within each group and between groups ( P < .05). The random-effect model was used to account for heterogeneity. The random-effects model was chosen a priori for all meta-analyses to account for the anticipated clinical and methodological heterogeneity across studies, as we expected variations in intervention protocols, patient characteristics, and outcome measurements. Heterogeneity was quantitatively assessed using the I 2 statistic, interpreted as follows: 0% to 40% might not be important; 30% to 60% may represent moderate heterogeneity; 50% to 90% may represent substantial heterogeneity; and 75% to 100% represents considerable heterogeneity. The Cochran’s Q test (with a significance level of P < .1) was also used to confirm the presence of heterogeneity. In cases of substantial heterogeneity ( I 2 > 50%), we investigated potential sources through a careful examination of the study characteristics, interventions, and populations. R statistical software (version 4.4.1) was used for meta-analysis. 10
Results
Study selection
Nine hundred seventy-four studies were initially identified across 346 PubMed, 98 ScienceDirect, 186 Cochrane, 327 CINAHL, and 17 from other sources. After removing 77 duplicates, 897 articles remained. Of these, 794 were excluded after title and abstract screening. Full-text screening of the remaining 103 articles led to the exclusion of 69 studies (reasons mentioned in Figure 1 ). Finally, 34 studies met the inclusion criteria and were included in the systematic review, and 22 were included in the meta-analysis, as illustrated in the PRISMA flowchart ( Figure 1 ).
Study characteristics
Involving 1903 patients with MS across 32 RCTs and clinical trials, and 2 quasi-experimental trials. The number of participants in each trial varied, ranging from 20 to 120 patients.
Patients’ information
All patients with MS in the included studies had a mean age of 38.73 ± 7.1 years. However, two studies did not report the mean age. 11 , 12 Males accounted for only 9% of the participants, and females accounted for 91% in all included studies. The mean duration of MS was 8.1 ± 4.4 years, as reported by most studies. However, 10 studies did not report the disease duration. 11-20 The mean EDSS score was 2.8 ± 1.15 in most of the included studies. Only eight studies reported the included type of MS: four studies included RR/PP/SP, 16 , 19 , 21 , 22 two studies included RR alone, 11 , 12 one study included RR/RP/SP, 23 and one study included RR/PP. 24
Intervention characteristics
In the context of rehabilitation interventions, eight different treatment approaches were identified across 15 studies, with two studies incorporating two interventions alongside a control group. 13 , 25 Four studies examined the effectiveness of pelvic floor muscle training either alone 26 , 27 or in combination with intravaginal electrical stimulation 25 or mindfulness, 28 with protocols lasting 8 to 12 weeks. Six studies focused on exercise-based interventions, including aerobic exercises (two studies), aquatic exercises (two studies), and treadmill training (two studies), each involving 16 to 130 exercise sessions, each lasting 30 to 60 min. 13 , 29-33 Additionally, four studies investigated the effects of yoga exercises, with protocols ranging from 8 to 24 sessions and session durations of 60 to 120 min. 13-15 , 34 Another one study applied transcutaneous tibial nerve stimulation, with protocols ranging from 4 to 12 weeks and session durations of 30 min. 24 Lastly, one study examined the efficacy of virtual reality (VR) exercises combined with cognitive therapy, with sessions lasting 60 min over 8 weeks, 20 and one study evaluated an Autogenic training program (a daily relaxation intervention lasting for 15 min) over 10 weeks. 35
On the other hand, the psychoeducational and other interventions were assessed in 19 studies. Among these, 16 studies focused on various models of educational interventions and counseling. Four studies employed the PLISSIT model, with interventions lasting 4 weeks and sessions running for 90 min each. 17 , 19 , 36 , 37 The PLISSIT model (comprising Permission (P), Limited Information (LI), Specific Suggestions (SS), and Intensive Therapy (IT)) is a widely recognized and effective framework for sex therapy. Whereas, three studies applied the EX-PLISSIT model for 4-12 weeks, with sessions running for 90 min each. 21 , 38 , 39 The EX-PLISSIT model builds on the original PLISSIT framework by allowing for intensive therapy to be introduced at any stage of managing SD and offers greater flexibility by enabling therapists to tailor interventions more dynamically to the patient’s needs. Additionally, two studies implemented Orem-based educational programs and Pythagorean self-awareness (self-care programs), consisting of 8 to 9 sessions, each lasting 45 to 90 min, 12 , 40 respectively. Two studies incorporated eight sessions (60-90 min each) of social work and Compassion-Focused Therapy. 18 , 41 Furthermore, three studies evaluated general sexual education programs, with interventions spanning 3 to 12 sessions, each lasting 90 min. 16 , 22 , 42 Three studies explored sexual counseling interventions, with protocols ranging from 3 to 6 sessions, each lasting 30 to 60 min. 23 , 43 , 44 One study applied a Mindfulness Psychoeducational Intervention, delivered over five sessions lasting 90 min each. 11 Lastly, one study examined the expressive writing treatment method over 6 weeks. 45 Detailed characteristics of these interventions are provided in Table 1 .
Table 1
Data extraction and study characteristics.
Abbreviations: CG: control group, CIS: clinically isolated syndrome, EDSS: Expanded Disability Status Scale, TG: treatment group, E: endurance, ECT: every contraction timed, EMG: electromyography, EX-PLISSIT: Expansion PLISSIT, F: female, F: fast contractions, and finally FSDS-R: female sexual distress scale-revised, FSFI: Female sexual function index, FFS: Family Functioning Scale, GMREL: Global Measure of Relation Satisfaction, GMSEX: Global Measure of Sexual Satisfaction, IIQ: incontinence impact questionnaire, ISS: index of sexual satisfaction, LSSQ: Larson sexual satisfaction scale questionnaire, M: male, min: minute, MS: multiple sclerosis, MSISQ-19: multiple sclerosis intimacy and sexuality questionnaire, MSLQI: Multiple sclerosis quality of life inventory, MSPS: multiple sclerosis perceived stigma scale, MSQOL-54: Multiple sclerosis quality of life-54, n : number, NMES: neuromuscular electrical stimulation, PERFECT: P: power, PFMT: pelvic floor muscle training, PLISSIT: Permission Limited Information Specific Suggestions Intensive Therapy, PP: primary progressive, PR: progressive-relapsing, PVR: post-voiding residue, 3-QLI: 3-Item Quality of Life Index, R: repetitions, RCT: randomized controlled trial, RR: relapsing–remitting, SP: secondary progressive, SQOL-F: sexual quality of life scale – female version, tDCS: transcranial direct current stimulation, TTNS: transcutaneous tibial nerve stimulation, VR: virtual reality.
| Author | Patients’ info | Intervention-sessions number and duration—sample | Frequency | Evaluations schedule | Outcome |
| Sutherland 2001 30 | Age means: 46.3 ± 4.9, M/F: 10/12, MS duration (years): 10.77 ± 4.61, EDSS: NA | TG = Aerobic Exercise, 30 sessions/45 min, n = 11. CG = Observation group, n = 11. | 10 weeks | Post-intervention | MSQOL-54 |
| Romberg 2005 31 | Age means: 43.85 ± 6.7, M/F: 34/61, MS duration (years): 6.25 ± 6.5, EDSS mean: 2.51 ± 1.3 | TG = Resistance + aerobic exercise, 5 times a week/30 min, n = 47. CG = Observation group, n = 48. | 26 weeks | Post-intervention 26 weeks | MSQOL-54 |
| Sutherland 2005 35 | Age means: 42.2 ± 7.7, M/F: 6/16, MS duration (years): 7.9 ± 4.61, EDSS mean: NA | TG = Autogenic training program (relaxation intervention), n = 11. CG = Observation group, n = 11. | 10 weeks | Post-intervention | MSQOL-54 |
| Christopherson 2006 23 | Age means: 44 ± 7.7, M/F: 0/62, MS type: RR/RP/CIS/Stable, MS duration (years): 11.3 ± 6.5, EDSS mean: 3.6 ± 0.5 | TG = Received written materials + counseling session, 3 sessions/10-30 min, n = 31. CG = written materials, n = 31. | 24 weeks | Post-intervention | MSISQ-19 |
| Ahmadi 2010 A 32 | Age means: 36.75 ± 9, M/F: 0/20, MS duration (years): 5.3 ± 3.1, EDSS mean: 2.32 ± 1.21 | TG = Treadmill training, 24 sessions/30 min, n = 10. CG = Routine, n = 10. | 8 weeks | Post-intervention | MSQOL-54. |
| Ahmadi 2010 B 34 | Age means: 34.38 ± 9.05, M/F: 0/21, MS duration (years): 4.85 ± 4.47, EDSS mean: 2.11 ± 1.15 | TG = Yoga exercise, 24 sessions/60 min, n = 11. CG = Observation group, n = 10. | 8 weeks | Post-intervention | MSQOL-54. |
| Kargarfard 2012 29 | Age means: 32.65 ± 8.1, M/F: 0/21, MS type: RR, MS duration (years): 4.75 ± 2.1, EDSS mean: 2.95 ± 0.8 | TG = Aquatic exercise, 24 sessions/60 min, n = 10. CG = Routine, n = 11. | 8 weeks | 4 weeks Post-intervention and 8 weeks follow-up | MSQOL-54 and MFIS |
| Ahadi 2013 13 | Age means: 34.15 ± 8, M/F: 0/31, MS duration (years): NA, EDSS mean: NA. | TG1 = Yoga exercise, 24 sessions/60-70 min, n = 11. TG2 = Treadmill training, 24 sessions/30 min, n = 10. CG = Routine, n = 10. | 8 weeks | Post-intervention | MSQOL-54 |
| Lúcio 2014 25 | Age means: 46.1 ± 8.5, M/F: 0/30, MS duration (years): 12.3 ± 4.4, EDSS mean: 4 ± 1 | TG1 = PFMT + EMG + intravaginal NMES, 24 sessions/30 min, n = 10. TG2 = PFMT + EMG + TTNS, 24 sessions/30 min, n = 10. CG = PFMT + EMG + sham NMES, n = 10. | 12 weeks | Post-intervention | FSFI |
| Najafidoulatabad 2014 14 | Age means: 31.6 ± 8, M/F: 0/60, MS duration (years): NA, EDSS mean: NA | TG = Yoga exercises, 24 sessions/60-90 min, n = 30. CG = Routine, n = 30. | 12 weeks | Post-intervention | MSQOL-54: Sexual Satisfaction |
| Khakbazan 2016 36 | Age means: 35.2 ± 6.3, M/F: 0/88, MS duration (years): 6.33 ± 4.5, EDSS mean: 2.04 ± 1.1 | TG = PLISSIT, 1 session/90 min, n = 43. CG = Observation group, n = 45. | 4 weeks | 2 months post-intervention and 3 M follow-up | FSFI |
| Nejati 2016 15 | Age means: 32.3 ± 5.1, M/F: 13/11, MS duration (years): NA, EDSS mean: NA | TG = Yoga exercises, 8 sessions/120 min, n = 12. CG = Observation group, n = 12. | 8 weeks | Post-intervention | MSQOL-54. |
| Zamani 2017 42 | Age means: 35.5 ± 7, M/F: 0/30, MS duration (years): 4.5 ± 3.7, EDSS mean: NA | TG = Sex education, 12 sessions/_, n = 15. CG = Observation group, n = 15. | 12 weeks | Post-intervention | MSQOL-54 and FSFI |
| Daneshfar 2017 38 | Age means: 55.9 ± 8.05, M/F: 0/120, MS duration (years): 10.5 ± 3.3, EDSS mean: 2.3 ± 1 | TG = Ex-PLISSIT, 32 sessions/60-100 min, n = 60. CG = Routine, n = 60. | 8 weeks | Post-intervention, and a 12-week follow-up | MSISQ-19 |
| Mosalanejad 2018 28 | Age means: 35.7 ± 6.5, M/F: 0/70, MS duration: 4.9 ± 3.1, EDSS mean: NA | TG1 = PFMT + Mindfulness, 8 sessions/90 min, n = 25. TG2 = PFMT, 8 sessions/90 min, n = 25. CG = mindfulness program, n = 25 | 8 weeks | 8 weeks Post-intervention and 12 weeks follow-up | FSFI |
| Arshi 2020 41 | Age means: 35.95 6.41, M/F: 0/58, MS duration (years): 5.4 ± 4.1, EDSS mean: NA | TG = Social work, 8 sessions/60 min, n = 28. CG = Observation group, n = 30 | _ | Post-intervention | MSISQ 19 ISS |
| Bahmani 2020 33 | Age means: 37.19 ± 7.7, M/F: 0/60, MS duration (years): 7.26 ± 3.9, EDSS mean: 2 ± 0.5 | TG1 = Aquatic exercise, 24 sessions/60 min, n = 18. TG2 = Aquatic exercise, 16 sessions/60 min, n = 20. CG = Routine, n = 22. | 8 weeks | Post-intervention | FSFI and couple satisfaction |
| Azari‑Barzandig 2020 21 | Age means: 36.6 ± 6, M/F: 0/70, MS type: RR/PP/SP/PR, MS duration (years): 4.7 ± 2.8, EDSS mean: NA | TG = EX-PLISSIT, 1 session/60-90 min, n = 35. CG = Routine, n = 35. | 8 weeks | Post-intervention and 2-month follow-up | MSISQ-19 SQOL-F |
| Ahani 2021 11 | Age means: -, M/F: 0/47, MS duration (years): NA, EDSS mean: NA | TG = Mindfulness-Based Group Psychotherapy, 5 sessions/90 min, n = 24. CG = Observation group, n = 23. | 2 weeks | Post-intervention | FSFI |
| Dunya 2021 24 | Age means: 42.8 ± 7.74, M/F: 0/30, MS type: RR/PP, MS duration (years): 13.7 ± 9.4, EDSS mean: 3.40 ± 1.52 | TG = TTNS, daily/30 min, n = 10. CG = PFMT, twice a day/30 min, n = 20 | 6 weeks | Post-intervention | FSFI, SQOL‐F |
| Kazemi 2021 37 | Age means: 35.8 ± 7, M/F: 0/62, MS duration (years): 9 ± 6.2, EDSS mean: NA | TG = PLISSIT, 4 sessions/45-75 min, n = 31. CG = Observation group, n = 31. | 4 weeks | 2 weeks Post-intervention and 8 weeks follow-up | SQOL-F |
| Sazesh 2021 43 | Age means: 34.5 ± 7, M/F: 0/72, MS duration: 6.8 ± 0.5, EDSS mean: 2.3 ± 1.15 | TG = Group counseling based on the client-centered approach, 6 sessions/60 min, n = 36. CG = Routine, n = 36. | _ | Post-intervention and1-month follow-up | LSSQ |
| Jamalianfar 2021 16 | Age means: 37.27 ± 6.18, M/F: 0/80, MS type: RR/PP/SP, MS duration (years): NA, EDSS mean: NA | TG = Educational program, 3 sessions/90 min, n = 40. CG = Observation group, n = 40. | 1 week | Post-intervention | ISS SIS |
| Ahani 2022 12 | Age means: -, M/F: 0/46, MS duration (years): NA, EDSS mean: NA | TG = Pythagorean self-awareness, 8 sessions/_, n = 23. CG = Observation group, n = 23. | _ | Post-intervention, 4-8 weeks follow-up | SQOL-F |
| Ghafoori 2022 44 | Age means: 37.32 ± 6.75, M/F: 0/71, MS duration (years): 9.5 ± 6, EDSS mean: 2.9 ± 1.35 | TG = BETTER model-based counseling and routine care, 4 sessions/60-90 min, n = 36. CG = Routine, n = 35. | _ | 8 weeks Post-intervention and 12 weeks follow-up | FSFI, ISS |
| Ghasemi 2022 22 | Age means: 35.71 ± 7.44, M/F: 0/65, MS type: RR/PP/SP, MS duration (years): 8 ± 5.3, EDSS mean: NA | TG = Educational sexual interventions, 6 sessions/60-90 min, n = 32. CG = Routine, n = 33. | 6 weeks | Post-intervention, 4 weeks, and 8 weeks follow-up | MSISQ-19 SQOL |
| Afshar 2023 45 | Age means: 33.84 ± 7.08, M/F: 0/58, MS duration (years): 5.48 ± 3.36, EDSS mean: 1.84 ± 0.89 | TG = Expressive writing, n = 29. CG = Routine, n = 29. | 6 weeks | Post-intervention, 4 weeks, and 8 weeks follow-up | MSISQ-19 |
| Yavas 2023 26 | Age means: 44.7 ± 9.5, M/F: 9/36, MS type: RR, MS duration (years): 15.2 ± 8.05, EDSS mean: 3.8 ± 1.6 | TG1 = PFMT home training, 3 times daily, n = 15. TG2 = Tele-PFMT, 3 times daily, n = 15. CG = Observation group, n = 15. | 8 weeks | 4 weeks Post-intervention,8-12 weeks follow-up | MSISQ-19 |
| Nazari 2023 39 | Age means: 35.6 ± 4, M/F: 0/74, MS duration (years): 11.16 ± 2.35, EDSS mean: NA | TG1 = Ex‑PLISSIT, 4 sessions/60-90 min, n = 37. CG = Observation group, n = 37. | 4 weeks | 4 weeks post-intervention and 8 weeks follow-up | FSDS-R LSSQ |
| Tzitzika 2023 17 | Age means: 48.7 ± 6.1, M/F: 60/60, MS duration (years): NA, EDSS mean: NA | TG1 = PLISSIT, n = 40. TG2 = psychoeducation, n = 40. CG = Observation group, n = 40. | 10 weeks | Post 10 weeks and 6 months follow-up | MSISQ-15 GMSEX GMREL |
| Sheykhangafshe 2023 18 | Age means: 33.8 ± 7.54, M/F: 0/30, MS duration (years): NA, EDSS mean: NA | TG = Compassion-Focused Therapy, 8 sessions/90 min, n = 15. CG = Observation group, n = 15. | 4 weeks | Post-intervention | FSFI Resilience Questionnaire |
| Zachariou 2024 27 | Age means: 38.7 ± 4.15, M/F: 0/69, MS duration (years): 7.8 ± 2.7, EDSS mean: 2.2 ± 0.95 | TG = PFMT, 30 min daily, n = 33. CG = Observation group, n = 36. | 12 weeks | Post-intervention | FSFI FSDS-R |
| Maggio 2024 20 | Age means: 49.2 ± 9.7, M/F: 30/40, MS duration (years): NA, EDSS mean: NA | TG = VR, 24 sessions/60 min, n = 35. CG = Cognitive rehabilitation, n = 35. | 8 weeks | Post-intervention | MSQOL-54 |
| Sohrabi 2024 19 | Age means: 35.4 ± 5.5, M/F: 0/60, MS type: RR/PP/SP, MS duration (years): NA, EDSS mean: NA | TG = PLISSIT, 4 sessions/90 min, n = 30. CG = Routine, n = 30. | 4 weeks | Post-intervention | SQOL-F FFS |
Outcomes characteristics
Five outcome measures and scales were identified for sexual function and satisfaction outcomes. For both genders (male and female), 11 studies utilized the multiple sclerosis quality of life – sexual function domains (MSQOL-54), 13-15 , 20 , 29-32 , 34 , 35 , 42 seven studies employed a sexual satisfaction questionnaire (eg, Larson sexual satisfaction scale (LSSQ), Index of sexual satisfaction (ISS), Global measure of sexual satisfaction (GMSEX), Global Measure of Relationship Satisfaction (GMREL), 14 , 16 , 17 , 39 , 41 , 43 , 44 and eight studies utilized the MS intimacy and sexuality questionnaire (MSISQ-19 or MSISQ-15) to evaluate intimacy and SD. 17 , 21-23 , 26 , 38 , 41 , 45 Whereas, six studies employed the sexual quality of life questionnaire for females (SQOL-F), 12 , 19 , 21 , 22 , 24 , 37 and 10 studies used the Female Sexual Function Index (FSFI) to assess sexual functions in females only. 11 , 24 , 25 , 27 , 28 , 33 , 36 , 42 , 44 , 46 Only one study used the female sexual distress scale-revised to examine sexual distress besides sexual function. 27 All study outcomes are shown in Table 1 .
Quality assessments
According to the Cochrane ROB-2 (Risk of Bias) tool, two studies were classified as having a low risk of bias, 23 were identified as having a high risk of bias, and nine had some concerns. The detailed results of the ROB-2 tool for studies evaluating sexual function are presented in Figure 2 .
Therapeutic effectiveness on sexual function
Four studies examined the impact of yoga exercises on sexual function, as measured by the MSQOL-54 sexual function domain. 13-15 , 34 A pooled analysis of these studies, involving 126 participants, revealed no significant improvement in sexual function among MS patients who practiced yoga compared to those receiving routine care [SMD = −0.18, P = .84, 95% CI: −2.04 to 1.68, I 2 = 0%] ( Figure 3 ).
However, five studies investigated the effectiveness of various exercise protocols (including two on treadmill training, two on aerobic exercises, and one on aquatic exercise) on sexual function, as measured by the MSQOL-54 sexual function domain. 13 , 29-32 A pooled analysis of these studies, involving 156 participants, demonstrated a significant improvement in sexual function among patients with MS who engaged in these exercises compared to those receiving routine care [SMD = 2.88, P = .04, 95% CI: 0.05 to 5.71, I 2 = 50%] ( Figure 4A ). Additionally, one study evaluated the impact of two aquatic exercise protocols (3 sessions/week and 2 sessions/week) on sexual function in females with MS using the FSFI. 33 The pooled analysis of this study, which included 60 participants, revealed a significant therapeutic effect of aquatic exercise on sexual function compared to routine care [SMD = 14.76, P = .0001, 95% CI: 7.31 to 22.22, I 2 = 79%] ( Figure 4B ). This analysis demonstrated moderate heterogeneity ( I 2 = 50%-79%), which could be attributed to the pooling of different exercise modalities (treadmill and aerobic).
Furthermore, two studies assessed the effectiveness of mindfulness therapeutic sessions on sexual function in females with MS, as evaluated by the FSFI. 11 , 18 The pooled analysis of these studies, involving 77 participants, showed a significant improvement in sexual function among those who participated in mindfulness sessions compared to routine care [SMD = 4.40, P < .0001, 95% CI: 2.79 to 6.02, I 2 = 0%] ( Figure 5 ).
On the other hand, four studies investigated the therapeutic effectiveness of sexual psychoeducational programs (three utilizing the PLISSIT model and one focusing on sex education) on the overall SQOL-F with MS, as assessed by the SQOL-Female version. 19 , 21 , 22 , 37 A pooled analysis of these four studies, involving 257 participants, found no significant therapeutic effect of psychoeducational programs on overall females’ sexual quality of life compared to routine care [SMD = 16.40, P = .18, 95% CI: −7.76 to 40.57, I 2 = 98%] ( Figure 6A ). However, three studies evaluated the therapeutic effectiveness of sexual psychoeducational programs (two using the PLISSIT model and one based on the BETTER model of counseling) on sexual function in females with MS, as measured by the FSFI. 36 , 42 , 44 A pooled analysis of these three studies, which included 189 participants, demonstrated a significant improvement in sexual function among those who participated in psychoeducational programs compared to routine care [SMD = 3.46, P = .004, 95% CI: 1.08 to 5.84, I 2 = 97%] ( Figure 6B ). Additionally, five studies assessed the effectiveness of sexual psychoeducational programs (two employing the PLISSIT model and three involving counseling interventions) on sexual satisfaction in patients with MS, as evaluated by sexual satisfaction questionnaires. 16 , 17 , 39 , 43 , 44 A pooled analysis of these five studies, encompassing 371 participants, revealed a significant therapeutic effect of psychoeducational programs on sexual satisfaction compared to the control group [SMD = 7.73, P = .028, 95% CI: 0.80 to 14.66, I 2 = 87%] ( Figure 6C ). We observed substantial heterogeneity ( I 2 = 87%) in this pooled result, likely reflecting the diversity of psychoeducational models used (eg, PLISSIT, general counseling) and varying session durations across the included studies.
Discussion
The review emphasizes the therapeutic benefits of non-pharmacological rehabilitation interventions in the management of SDs in patients with MS. In short, the pooled analysis indicated a significant improvement in the sexual functioning and satisfaction of women in six different domains: desire, arousal, lubrication, orgasm, satisfaction, and pain in terms of FSFI, and female and male patients in terms of MSQOL-54 (sexual function domain) after physical and aquatic exercises, psychoeducational, and mindfulness therapies. However, yoga therapies showed no significant improvement in sexual function compared with routine care. Overall, the interpretation of the effect sizes, particularly the very high SMDs observed in some analyses (eg, aquatic exercise), requires caution. These magnitudes may not solely reflect a large treatment effect but could also be influenced by the small sample sizes of the contributing studies, the specific responsiveness of the outcome measures used (eg, the FSFI), or other study-specific factors. Therefore, while the direction of effect is clear, the precise magnitude should be viewed as provisional pending confirmation by larger, more robust trials.
Regarding data on sexual function, currently, there are only two systematic reviews without meta-analysis published in English 1 , 5 and one in French. 6 The two English reviews mainly provided a general summary of treatment choices, revealing a small number of studies. For example, Esteve-Ríos et al. (2020) 5 assessed interventions aimed at sexual health in women with MS, using a cutoff date of 2019. They recognized 12 clinical trials that included six intervention types: sexual therapy (4 studies), medication (3 studies), pelvic floor exercises (2 studies), yoga (1 study), mindfulness (1 study), and vaginal devices (1 study). In 2023, Giannopapas et al. 1 performed another systematic review examining the non-pharmacological treatment for SD in male and female patients with MS. Even with wider inclusion criteria and a search performed 2 years later, surprisingly, they found fewer studies (nine studies; six concentrating on non-pharmacological interventions, one study each on aquatic therapy, pelvic muscle training, yoga, mindfulness, and intravaginal electrical stimulation). This is because they limited their search to one database (PubMed Medline). Nevertheless, the narrative evaluation of both reviews found that the majority of interventions improved SD, including lubrication, arousal, desire, and orgasm.
However, several relevant RCT studies that met the inclusion criteria in both reviews were overlooked and not included. For example, we identified 4 yoga studies published between 2010 and 2016 (rather than one), 9 psychoeducational sexual therapy studies (instead of 4), 2 mindfulness studies (rather than 2), 5 exercise and pelvic muscle training studies (instead of 2), and one intravaginal study. Additionally, previous reviews lacked objective efficacy evaluations through meta-analysis and did not address a range of outcomes measured in the studies.
On the other hand, there is a single meta-analysis review 7 a 2021, thus it identified fewer related RCTs, focused on overall interventions (medical and nonmedical) for sexual function and dysfunction with no attention to sexual satisfaction, and missed other range of interventions, such as virtual reality, inter-vaginal-based electrical stimulation, and autogenic therapy. Therefore, this study will serve as the most comprehensive and up-to-date review, evaluating the efficacy of non-pharmacological rehabilitation interventions for managing SD in patients with MS by addressing the gaps and limitations of previous reviews such as overlooked studies, the absence of meta-analysis, and insufficient consideration of diverse outcomes to provide a thorough and evidence-based assessment of available interventions, offering valuable insights for clinical practice and future research.
Nevertheless, while this research emphasizes assessing the existing evidence, we can mention various reasons for this study’s significant and insignificant results. Concerning the absence of therapeutic effects of yoga therapy compared with mindfulness therapy, physical exercises, or aquatic exercises, one potential explanation might stem from the uncertainty about the yoga technique and methods used in the screened studies. 13-15 , 34 Although yoga has benefits for reproductive health as it can help stimulate hormones, improve blood circulation, and strengthen reproductive organs, there is still a wide range of yoga techniques, which come with various and different impacts on sexual function directly or indirectly. For example, mudras and Moola Bandha can achieve hormone balance and pelvic awareness, while seated poses and pranayama reduce stress and enhance arousal control. Therefore, the absence of significant impacts of yoga therapy on sexual function in patients with MS in this study is expected, as the screened studies 13-15 , 34 did not mention exactly which method of yoga was implemented. Besides the high risk of bias identified in the included screened studies, such lack of which yoga method has been used is also extended to be a possible explanation for the contrary results of the previous reviews. For example, a scoping review in 2023 47 revealed that yoga exercises significantly improved erectile and ejaculation function in healthy men based on reviewing three clinical trials and seven review articles. A very recent systematic review and meta-analysis study in 2024 examined the effectiveness of yoga intervention on sexual function in healthy adult individuals (males and females) 48 and identified 10 RCT studies on healthy individuals and reported that yoga has a small sexual function improvement in women and lacks evidence in terms of men. Moreover, we have to highlight that the quality assessment showed that, consequently, future yoga-related studies with more information on which yoga techniques have been implemented are needed.
Regarding the absence of significant impacts of psychoeducational intervention (PLISST, ground social counseling) on sexual quality of life (assessed by SQOL) compared with the significant therapeutic effects on sexual function and satisfaction (assessed by FSFI, ISS, GMSEX, GMREL, etc.). QOL is a time-vision outcome focused on the future time dimension, which is postmodern and relies on one’s ability to increase positive factors in the past, enjoy the present, and initiate long-term planning for a positive future to create a meaningful future that leads to personal growth. This helps people choose how to spend their time and plan their lives to achieve a higher QOL. Besides, such focusing people’s attention on the future (personal and sublime) helps them direct their lives toward a meaningful view of life. 49 Therefore, QOL models are considered long-term impact models. This assumption is supported by a previous study that examined the temporal vision of the SQOL in patients with chronic disease (eg, Diabetic Mellitus type 2), which showed that the implementation of time vision therapy has increased the average score of the subject’s quality of life in the final long-term point instead of an immediate post-test point. 50 Therefore, implementing time vision therapy and outcomes needs a mid-term and long-term follow-up measure to capture any potential impact or therapeutic effect, which has been missed in the identified screened studies in this review concerning the psychosocial educational therapies on SQOL. 13-15 , 34 In sum, the results for psychoeducational interventions present a nuanced picture. While these programs demonstrated significant benefits for core aspects of sexual health, specifically, sexual function and satisfaction, their effect on the broader construct of SQOL was not statistically significant. This discrepancy suggests that while psychoeducation is effective at addressing immediate sexual difficulties and improving satisfaction within the relationship, its current formats may be insufficient to translate these gains into a holistic and enduring sense of sexual well-being and quality of life. Therefore, the need for certain psychoeducational programs to require refinement is not a dismissal of their efficacy, but rather a call to optimize them to also positively impact this overarching, long-term outcome.
Limitations
Our systematic review has several limitations that should be acknowledged. As noted in the results, we observed considerable statistical heterogeneity ( I 2 > 75%) in several meta-analyses, particularly for psychoeducational and exercise interventions on sexual function and satisfaction. The primary sources of this clinical and methodological heterogeneity are the diversity in intervention protocols (eg, different models of psychoeducation, various yoga techniques), session frequency and duration, and patient characteristics across the included studies. While we used a random-effects model to incorporate this heterogeneity and conducted a narrative investigation of its potential sources, we were unable to perform pre-planned subgroup or meta-regression analyses due to the insufficient number of studies within each intervention subcategory. Consequently, the pooled estimates for these outcomes should be interpreted with caution, as they represent an average effect across a diverse set of implementations. Future research with more standardized protocols and a larger body of evidence will allow for more robust explorations of these factors. Additionally, the small number of included studies with different measures limited our ability to explore potential subgroup effects and differences in treatment responses across different patient profiles. For example, due to the small number of studies, we were not able to systematically evaluate the effects of several identified treatment options, such as intravaginal electrical stimulation, Orem-based therapy, Pythagorean self-awareness, and virtual reality.
Conclusion, clinical implications, and future directions
The findings of this study have important clinical implications. For SD, tailored interventions such as aerobic exercises, aquatic exercises, and mindfulness-based therapies may offer significant benefits, while yoga and certain psychoeducational programs may require further refinement to enhance their effectiveness. Future research should focus on identifying patient-specific factors that influence the effectiveness of these interventions, such as disease severity, MS types, duration of symptoms, and individual preferences. Additionally, longitudinal studies are needed to assess the long-term benefits and sustainability of these therapies. More studies should be carried out on various promising treatment options. By addressing these gaps, clinicians can develop more personalized and effective treatment plans, ultimately improving the QOL for patients with MS.
Author contributions
H.H.: Conceptualization, Methodology, Investigation, Writing—Original Draft, Writing—Review & Editing, Project Administration. A.A.H.: Investigation, Data Curation, Formal Analysis, Writing—Original Draft. M.A-W.: Methodology, Investigation, Data Curation. M.E.: Methodology, Validation. A.A.-S.: Methodology, Validation.
Funding
None declared.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Registration
This study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024546632).
References
1. Giannopapas V , Kitsos D , Tsogka A , et al. Sexual dysfunction therapeutic approaches in patients with multiple sclerosis: a systematic review . Neurol Sci . 2023 ; 44 ( 3 ): 873 – 880 . 10.1007/s10072-022-06572-0 36585597 PMC9925549
2. Marck CH , Jelinek PL , Weiland TJ , et al. Sexual function in multiple sclerosis and associations with demographic, disease and lifestyle characteristics: an international cross-sectional study . BMC Neurol . 2016 ; 16 ( 1 ): 210 . 10.1186/s12883-016-0735-8 27814701 PMC5097380
3. Kessler TM , Fowler CJ , Panicker JN . Sexual dysfunction in multiple sclerosis . Expert Rev Neurother . 2009 ; 9 ( 3 ): 341 – 350 . 10.1586/14737175.9.3.341 19271943
4. Manaila AI , Roman NA , Baseanu ICC , et al. The efficiency of rehabilitation therapy in patients diagnosed with neurogenic bladder: a systematic review . Medicina (Kaunas) , 2024 ; 60 ( 7 ): 1152 . 10.3390/medicina60071152 39064583 PMC11278912
5. Esteve-Ríos A , Garcia-Sanjuan S , Oliver-Roig A , Cabañero-Martínez MJ . Effectiveness of interventions aimed at improving the sexuality of women with multiple sclerosis: a systematic review . Clin Rehabil . 2020 ; 34 ( 4 ): 438 – 449 . 10.1177/0269215520901751 32048535
6. Yavas I , Emuk Y , Kahraman T . Pelvic floor muscle training on urinary incontinence and sexual function in people with multiple sclerosis: a systematic review . Mult Scler Relat Disord . 2022 ; 58 : 103538 . 10.1016/j.msard.2022.103538 35066277
7. Afshar B , Amini L , Hasani M , Jahanfar S , Massood Nabavi S . The most effective sexual function and dysfunction interventions in individuals with multiple sclerosis: a systematic review and meta-analysis . Int J Reprod Biomed . 2022 ; 20 ( 4 ): 241 – 254 . 10.18502/ijrm.v20i4.10897 35822180 PMC9260072
8. Page MJ , Moher D , Bossuyt PM , et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews . BMJ . 2021 ; 372 : n160 . 10.1136/bmj.n160 33781993 PMC8005925
9. Sterne JAC , Savović J , Page MJ , et al. RoB 2: a revised tool for assessing risk of bias in randomised trials . BMJ . 2019 ; 366 : l4898 . 10.1136/bmj.l4898 31462531
10. Polanin JR , Williams RT . Overcoming obstacles in obtaining individual participant data for meta-analysis . Res Synth Methods . 2016 ; 7 ( 3 ): 333 – 341 . 10.1002/jrsm.1208 27228953
11. Ahani L , Department of psychology, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran , Chorami M , et al. The effect of mindfulness psych-educational group intervention on improving sexual function of women with multiple sclerosis . Prevent Care Nurs Midwifery J . 2021 ; 11 ( 4 ): 35 – 45 . 10.52547/pcnm.11.4.35
12. Ahani L , Chorami M , Sharifi T , Ghazanfari A , Adibi Sedeh I . The effectiveness of Pythagorean self-awareness intervention in improving the quality of sexual life of women with multiple sclerosis . J Shahrekord Univ Med Sci . 2022 ; 24 ( 3 ): 127 – 132 . 10.34172/jsums.2022.21
13. Ahadi F, Rajabpour M, Ghadamgahi A, Pouryousef Kaljahi M, Tabatabaee S M . Effect of 8-week aerobic exercise and yoga training on depression, anxiety, and quality of life among multiple sclerosis patients . Iran Rehabil J . 2013 ; 11 : 75 – 80 .
14. Najafidoulatabad S , Mohebbi Z , Nooryan K . Yoga effects on physical activity and sexual satisfaction among the Iranian women with multiple sclerosis: a randomized controlled trial . Afr J Tradit Complement Altern Med . 2014 ; 11 ( 5 ): 78 – 82 . 10.4314/ajtcam.v11i5.13 PMC4202522 25395709
15. Nejati S , Rajezi Esfahani S , Rahmani S , Afrookhteh G , Hoveida S . The effect of group mindfulness-based stress reduction and consciousness yoga program on quality of life and fatigue severity in patients with MS . J Caring Sci . 2016 ; 5 ( 4 ): 325 – 335 . 10.15171/jcs.2016.034 28032077 PMC5187553
16. Jamalianfar F , Riazi H , Firoozi A , Nasiri M , Montazeri A . The effectiveness of ‘good-enough sex model’ on sexual satisfaction and sexual intimacy in women with multiple sclerosis: a randomized trail . Sex Disabil . 2021 ; 39 ( 3 ): 507 – 519 . 10.1007/s11195-021-09691-2
17. Tzitzika M , Daoultzis CC , Kordoutis P . Sexual rehabilitation and relational satisfaction in people with multiple sclerosis and their partners . Sex Disabil . 2023 ; 41 ( 2 ): 289 – 305 . 10.1007/s11195-023-09785-z 37168976 PMC10019389
18. Bagheri-Sheykhangafshe F, Tajbakhsh K, Savabi Niri V, Bourbour Z, Otadi S . The effectiveness of compassion-focused therapy on pain catastrophizing, sexual function, and resilience in women with multiple sclerosis (MS) . Int J Behav Sci . 2023 ; 17 ( 3 ): 133 – 140 . http://doi: 10.30491/ijbs.2023.390694.1932
19. Sohrabi F , Tirgari B , Alizadeh S , Salehi S . The effect of sexual counseling based on the PLISSIT model on family functioning and sexual quality of life of women with multiple sclerosis . Sex Disabil . 2024 ; 42 ( 3 ): 553 – 566 . 10.1007/s11195-024-09864-9
20. Maggio MG , Rizzo A , Quartarone A , Manuli A , Calabrò RS . Virtual reality rehabilitation in patients affected by multiple sclerosis: impact on quality of life and sexual functions . Mult Scler Relat Disord . 2024 ; 84 : 105470 . 10.1016/j.msard.2024.105470 38350226
21. Azari-Barzandig R , Sattarzadeh-Jahdi N , Nourizadeh R , Malakouti J , Mousavi S , Dokhtvasi G . The effect of counseling based on EX-PLISSIT model on sexual dysfunction and quality of sexual life of married women with multiple sclerosis: a randomized controlled clinical trial . Sex Disabil . 2020 ; 38 ( 2 ): 271 – 284 . 10.1007/s11195-020-09617-4
22. Ghasemi V , Nabavi SM , Simbar M , et al. The effect of sexual health promotion package on sexual life in women with multiple sclerosis: designed based on the results of a mixed method study . Sex Disabil . 2022 ; 40 ( 1 ): 57 – 75 . 10.1007/s11195-021-09697-w
23. Christopherson JM , Moore K , Foley FW , Warren KG . A comparison of written materials vs. materials and counselling for women with sexual dysfunction and multiple sclerosis . J Clin Nurs . 2006 ; 15 ( 6 ): 742 – 750 . 10.1111/j.1365-2702.2005.01437.x 16684170
24. Polat Dunya C , Tülek Z , Kürtüncü M , Gündüz T , Panicker JN , Eraksoy M . Evaluating the effects of transcutaneous tibial nerve stimulation or pelvic floor muscle training on sexual dysfunction in female multiple sclerosis patients reporting overactive bladder . Neurourol Urodyn . 2021 ; 40 ( 6 ): 1661 – 1669 . 10.1002/nau.24733 34174117
25. Lúcio AC , D’Ancona CAL , Lopes MHBM , Perissinotto MC , Damasceno BP . The effect of pelvic floor muscle training alone or in combination with electrostimulation in the treatment of sexual dysfunction in women with multiple sclerosis . Mult Scler . 2014 ; 20 ( 13 ): 1761 – 1768 . 10.1177/1352458514531520 24876156
26. Yavas I , Kahraman T , Sagici O , et al. Feasibility of telerehabilitation-based pelvic floor muscle training for urinary incontinence in people with multiple sclerosis: a randomized, controlled, assessor-blinded study . J Neurol Phys Ther . 2023 ; 47 ( 4 ): 217 – 226 . 10.1097/NPT.0000000000000448 37306430
27. Zachariou A , Zikopoulos A , Sapouna V , et al. Supervised pelvic floor muscle training improves sexual function and diminishes sexual distress in women with relapsing-remitting multiple sclerosis: a randomised controlled study . J Pers Med . 2024 ; 14 ( 1 ): 88 . 10.3390/jpm14010088 38248789 PMC10820578
28. Mosalanejad F , Afrasiabifar A , Zoladl M . Investigating the combined effect of pelvic floor muscle exercise and mindfulness on sexual function in women with multiple sclerosis: a randomized controlled trial . Clin Rehabil . 2018 ; 32 ( 10 ): 1340 – 1347 . 10.1177/0269215518777877 29843529
29. Kargarfard M , Etemadifar M , Baker P , Mehrabi M , Hayatbakhsh R . Effect of aquatic exercise training on fatigue and health-related quality of life in patients with multiple sclerosis . Arch Phys Med Rehabil . 2012 ; 93 ( 10 ): 1701 – 1708 . 10.1016/j.apmr.2012.05.006 22609300
30. Sutherland G , Andersen M , Stoove M . Can aerobic exercise training affect health-related quality of life for people with multiple sclerosis? Journal of Sport & Exercise Psychology . 2001 ; 23 : 122 – 135 . 10.1123/jsep.23.2.122
31. Romberg A , Virtanen A , Ruutiainen J . Long-term exercise improves functional impairment but not quality of life in multiple sclerosis . J Neurol . 2005 ; 252 ( 7 ): 839 – 845 . 10.1007/s00415-005-0759-2 15765197
32. Ahmadi A , Arastoo A , Nikbakht M . The effects of a treadmill training programme on balance, speed and endurance walking, fatigue and quality of life in people with multiple sclerosis . International SportMed Journal . 2010 ; 11 : 389 – 397 .
33. Sadeghi Bahmani D , Motl RW , Razazian N , Khazaie H , Brand S . Aquatic exercising may improve sexual function in females with multiple sclerosis - an exploratory study . Mult Scler Relat Disord . 2020 ; 43 : 102106 . 10.1016/j.msard.2020.102106 32428843
34. Ahmadi A , Nikbakh M , Arastoo A , Habibi AH . The effects of a yoga intervention on balance, speed and endurance of walking, fatigue and quality of life in people with multiple sclerosis . Journal of Human Kinetics - J HUM KINET . 2010 ; 23 : 71 – 78 . 10.2478/v10078-010-0009-2
35. Sutherland G , Andersen MB , Morris T . Relaxation and health-related quality of life in multiple sclerosis: the example of autogenic training . J Behav Med . 2005 ; 28 ( 3 ): 249 – 256 . 10.1007/s10865-005-4661-2 16015459
36. Khakbazan Z , Daneshfar F , Behboodi-Moghadam Z , Nabavi SM , Ghasemzadeh S , Mehran A . The effectiveness of the permission, limited information, specific suggestions, intensive therapy (PLISSIT) model based sexual counseling on the sexual function of women with multiple sclerosis who are sexually active . Mult Scler Relat Disord . 2016 ; 8 : 113 – 119 . 10.1016/j.msard.2016.05.007 27456885
37. Kazemi Z , Mousavi MS , Etemadifar M . The effect of counseling based on the PLISSIT model on sexual quality of life of married women with multiple sclerosis referring to MS center in 2019: a randomized, controlled trial . Arch Womens Ment Health . 2021 ; 24 ( 3 ): 437 – 444 . 10.1007/s00737-020-01080-6 33175238
38. Daneshfar F , Behboodi-Moghadam Z , Khakbazan Z , et al. The influence of ex-PLISSIT (extended permission, limited information, specific suggestions, intensive therapy) model on intimacy and sexuality of married women with multiple sclerosis . Sex Disabil . 2017 ; 35 : 399 – 414 . 10.1007/s11195-017-9482-z
39. Nazari S , Keramatkar M , Moghdehipanah H , Olfati F . The effect of ex-PLISSIT model on sexual satisfaction in women with multiple sclerosis . Sex Disabil . 2023 ; 41 ( 2 ): 467 – 477 . 10.1007/s11195-023-09787-x
40. Dahmardeh H , kianian T , Vagharseyyedin SA . Effect of Orem-based self-care education program on disease-related problems in patients with multiple sclerosis: a clinical trial . Med Surg Nurs J . 2030 ; 6 ( 1 ): e67854 .
41. Arshi M , Sheybani F , Eghlima M , Shati M , Moghanibashi-Mansourieh A , Moshayyedi M . Group social work intervention enhances the sexual satisfaction of women with multiple sclerosis: a randomized controlled trial study . Soc Work Health Care . 2020 ; 59 ( 5 ): 322 – 333 . 10.1080/00981389.2020.1762148 32420825
42. Zamani M , Tavoli A , Yazd Khasti B , Sedighimornani N , Zafar M . Sexual therapy for women with multiple sclerosis and its impact on quality of life . Iran J Psychiatry . 2017 ; 12 ( 1 ): 58 – 65 . 28496503 PMC5425353
43. Sazesh S, Esmaelzadeh Saeieh S, Farid M, Refaei M, Yazdkhasti M. Effectiveness of group counseling with a client-centered approach based on the GATHER principles on sexual satisfaction in women with multiple sclerosis: a randomized clinical trial . Iran J Med Sci . 2021 ; 46 ( 2 ): 103 – 111 . 33753954 10.30476/ijms.2020.82616.1074 PMC7966937
44. Ghafoori F , Bagheri M , Dehghan-Nayeri N , et al. Effectiveness of sexual Counseling using BETTER model to promote sexual function and satisfaction of married women with multiple sclerosis . Sex Disabil . 2022 ; 40 ( 3 ): 471 – 486 . 10.1007/s11195-022-09746-y
45. Afshar B , Amini L , Nabavi SM , et al. What effects can expressive writing have on sexual dysfunction in women with multiple sclerosis? A randomized controlled trial . Acta Neurol Scand . 2023 ; 2023 ( 1 ): 1 – 13 . 10.1155/2023/6754178
46. Bagheri-Sheykhangafshe F, Tajbakhsh K, Savabi Niri V, Bourbour Z, Otadi S. The effectiveness of compassion-focused therapy on pain catastrophizing, sexual function, and resilience in women with multiple sclerosis (MS) . Int J Behav Sci . 2023 ; 17 : 133 – 140 .
47. Bhat S , Pandey MK , K U , Gokani N , Rao TSS . A scoping review: is yoga an effective intervention for erectile dysfunction and premature ejaculation? Cureus . 2024 ; 16 ( 1 ): e53265 . 10.7759/cureus.53265 38435916 PMC10905059
48. Rodrigues AMBP, Neto OB, Seguro CS , et al. Does yoga improve sexual function? A systematic review and meta-analysis of randomized clinical trials . Complement Ther Clin Pract . 2024 ; 56 : 101864 . 10.1016/j.ctcp.2024.101864 38830273
49. Olivera-Figueroa LA , Muro A , Feliu-Soler A , et al. The role of time perspective and mindfulness on life satisfaction in the United States of America, Spain, Poland and Japan: a cross-cultural study . Curr Psychol . 2023 ; 42 ( 21 ): 17682 – 17699 . 10.1007/s12144-022-02756-1 37680300 PMC10482053
50. Rahimi S, Mikaeli N, Narimani M, Basharpour S. The effectiveness of time perspective therapy on the quality of life related to health and the health locus of control in patients with type 2 diabetes and sexual dysfunction . Prevent Counsel . 2024 ; 5 ( 2 ): 16 – 33 .
Appendix
Searching strategy
PubMed
((``Multiple Sclerosis''[Mesh] OR ``Multiple Sclerosis, Relapsing-Remitting''[Mesh] OR ``Multiple Sclerosis, Chronic Progressive''[Mesh] OR ``Leukodystrophy, Demyelinating, Adult-Onset, Autosomal Dominant'' [Supplementary Concept] OR ``demyelinating factors'' [Supplementary Concept]) AND (``Sexual Health''[Mesh] OR ``Sexual Behavior''[Mesh] OR ``Sexuality''[Mesh] ))
Cochrane
Multiple sclerosis in Title Abstract Keyword AND ``sexual function'' in Title Abstract Keyword - (Word variations have been searched)
Science Direct
((``Multiple Sclerosis''[Mesh] OR ``Multiple Sclerosis, Relapsing-Remitting''[Mesh] OR ``Multiple Sclerosis, Chronic Progressive''[Mesh]) AND (``Sexual Health''[Mesh] OR ``Sexual Behavior''[Mesh] OR ``Sexuality''[Mesh]))
CINHEL
“Multiple sclerosis or MS or multiple-sclerosis” AND “Sexual Health”