Mechanisms of visceral pain and hyperalgesia

Fernando Cervero
Director, The Alan Edwards Centre for Research on Pain
McGill University, Montreal, Canada
President, IASP

Working together for pain relief throughout the world

VISCERAL PAIN and ANALGESIA

Visceral pain is the most frequent form of pain
Few (if any) analgesics specifically directed at visceral pain conditions

Sociological reasons:

Patients often seen by practitioners with no primary interest in pain
treatment

Biological reasons:

inadequate animal models of visceral pain

unawareness of specifics of visceral pain

An unglamorous kind of pain

Sleep and pain tend to inspire poets and philosophers

(micturition and defecation do not)
with psychoanalysts is the other way round
(Peter Nathan)

Mechanistic features of visceral Pain

Sensory receptors / Nociceptors:
Intensity encoders as well as high threshold (summation?)
Chemosensitive ( ischemia sensitive)
Sensitization + profound changes in microenvironment
(secretory, motility, hormonal)
Many non-sensory receptors (CNS actions). Can they become
sensory under pathological conditions ? (IBS?)

SP in a mucosal afferent ending (ureter)

Semenenko & Cervero (1992)

Thresholds of ureteric afferents

Cervero & Sann (1989)

LUMEN

Role of the urothelium in

the signalling of sensory
events in the bladder

BLADDER

TRPV1
Fullness

vanilloids

Pain
Bladder reflexes

Urothelial
cell

ATP
P2X3

distension

Primary afferent neuron

?
TRPV1
?

Effect of the presence of

an experimental calculus
on the motility of the rat
ureter in vivo.
(Laird, Roza & Cervero 1997)

Role of Nav1.8 in hyperalgesia

No role in responses to acute mechanical stimuli
No role in responses to non-neurogenic inflammatory
stimuli
Required for sustained behavioral responses to
neurogenic inflammatory stimuli
Therefore:
Nav1.8 contributes to spontaneous activity in
sensitized nociceptors

Laird, et al. (2002) J.Neurosci. 22, 8352

Co--expression of CB1 and P2X3 receptors

Co
CB1 receptors are expressed in the urothelium and in nerve fibers of the
muscular and sub-urothelial layers
CB1 and P2X3 are co-expressed in the urothelium
CB1 receptor

P2X3 receptor

Merged

L = lumen
Bar = 20m

Negative control

Co--expression of CB1 and TRPV1 receptors

Co
CB1 and TRPV1 are co-expressed in umbrella cells
Some nerve fibers of the sub-urothelial and muscular layers co-express CB1
and TRPV1 receptors

Muscular layer

Urothelium +
Suburothelial
layer

Overall

CB1 receptor

TRPV1 receptor

Merged

*
L

*
*
*

L = lumen
Bar = 20m

Co--expression of CB1 and Substance P

Co
CB1 and Substance P are co-expressed in nerve fibers of the sub-urothelial layer.
Sparse co-localization of CB1 and Substance P in the muscular layer.
Substance P

Merged

Overall

CB1 receptor

Muscular layer

Urothelium +
Suburothelial
layer

L = lumen
Bar = 20m

Cyclophosphamide Cystitis: Behavior

Number of abdominal contractions

(during 5 minute periods)
20
18
16
14
12
10
8
6
4
2
0

Number of micturitions
(during 20 minute periods)
14

Saline

12

CYP
10
8
6
4
2
0

Saline
CYP

Cyclophosphamide Cystitis: Physiology

Volume infused
to reach 40 mm Hg (l)
180

Firing threshold (mm Hg)

12

160
10

140
120

**
*

100
80

60

40
20

0
Normal

CYP

Normal

CYP

Cannabinoid agonist (CB1/CB2) reverses sensitization

Normal

CYP pre AZ12646915

CYP post AZ12646915

100 V

40
Intravesical
pressure (mm Hg)
0
30
Afferent
activity
(spikes/s)
0
Waveform

Afferent activity (spikes/s)

25

Normal
CYP pre AZ12646915

20

CYP post AZ12646915

15
10
5

+
0

10

15

20

Intravesical pressure (mm Hg)

25

30

35

40

10 s

Normalized activity (%)

(versus pre-drug maximal activity)

Sensitization reversal is mediated by CB1 receptors

100

CYP pre AZ12646915

80

CYP post AZ12646915

60
40
20
0
0

10

15

20

25

30

35

40

Intravesical pressure (mm Hg)

CYP pre
AZ12646915 +
AM251
CYP post
AZ12646915 +
AM251

Normalized activity (%)

(versus pre-drug maximal activity)

140
120
100

100
90
80
70
60
50
40
30
20
10
0

80
60
40
20
0
0

10

15

20

25

30

35

40

CYP pre
AZ12646915 +
AM630
CYP post
AZ12646915 +
AM630

Intravesical pressure (mm Hg)

10

15

20

25

30

35

40

Cannabinoids and visceral nociceptors

Cannabinoid receptor CB1 mRNA is present in the urinary bladder
(urothelium, and nerve fibers). CB1, TRPV1 and P2X3 receptors are
coco-expressed.
Intravesical administration of a cannabinoid receptor agonist reduces the
mechanically--evoked activity of bladder afferents. This effect is
mechanically
abolished by the previous administration of a CB1 antagonist.
Afferent activity in inflamed bladders is increased for intravesical pressures
between 10 and 40 mmHg. Local treatment with a CB1/CB2
cannabinoid agonist significantly reduces afferent activity at
intravesical pressures above 20 mmHg. This effect is mediated by CB1
receptors.
Cannabinoid CB1 receptors are implicated in the peripheral modulation of
bladder sensory information by a direct action of cannabinoids on
nociceptive afferents

Mechanistic features of visceral Pain

CNS / central organization:
Evidence against brief/short lived nociceptive pain (no visceral
tail flick equivalent)
Alarm system with widespread motor and autonomic reactions
(trip-wire arrangement)
fMRI data: some (relatively minor) differences in activated brain
areas (mostly concerned with non-sensory aspects:
emotional, affective)

Viscero-somatic convergence in the spinal cord

Pain and spinal cord

hyperexcitability
the irritable focus
focus
From: J. MacKenzie (1909)

..this portion of the spinal

cord may be looked upon as
being rendered abnormally
excitable in consequence of a
violent stimulation from the
organ V..

How visceral pain works

Nociceptor
Primarysensitization

Hyperalgesia

CNS
A
/C

Synaptic
strengthening by
incoming
afferent volleys
(sensitization)

T
Referred
Hyperalgesia

A
/C

Allodynia
Activation of

nociceptive
neurons by LT
afferents

Synaptic
strengthening by
incoming
afferent volleys
(sensitization)

Visceral Hyperalgesia and

CNS hypersensitivity:
Role of glutamate
receptor trafficking
A. Contractor, S.F.Heinemann Sci. STKE 2002, RE14 (2002)

Visceral painful stimuli recruit GluR1 AMPA receptor

subunits to the membrane
5

MEMBRANE

GluR1

GluR2/3

10
45 90 180
Capsaicin (min)

** GluR1
*

**

**

GluR2/3

1
0
10

45

90

180

Time after capsaicin instillation (min)

CYTOSOL
GluR1
GluR2/3

10

45
90 180
Capsaicin (min)

Galan, Laird and Cervero, 2004

Mobilization by exocytosis?

Inhibition of the exocytosis pathway blocks recruitment of

GluR1 to the membrane and reduces referred hyperalgesia
Brefeldin A given i.t. 10 min before intracolonic capsaicin
MEMBRANE

45 min
100

Baseline
Vh + Capsaicin
Caps + 15 nmoles BFA

80

Vh

BFA
60

Capsaicin
2.0

**

40

**

1.5

**
**

20

**

1.0

0
1

0.5

16

Force (mN)

0.0

Capsaicin

Galan et al , 2004

32

AMPA trafficking and visceral pain

Acute painful stimuli induce trafficking (membrane delivery) of
GluR1 AMPA receptors in vivo
Inhibition of AMPA trafficking reduces secondary hyperalgesia
induced by acute stimuli

Functional Pain
Spontaneous and persistent pain in the
absence of an apparent cause
Frequent

form of chronic pain

(Irritable Bowel Syndrome, Interstitial Cystitis,
Chronic Pelvic Pain, Fibromyalgia.)
>30% all chronic pain

More prevalent in women (> 65%)

Unknown mechanisms (a role for estrogen?)

Functional Pain and Hyperalgesia

Spinal Cord
Genetic factors
Persistent pain
Hormones
Cognitive factors

T
Secondary
Hyperalgesia

A
/C

Allodynia

OVX induces a long lasting

abdominal mechanical hyperalgesic state

100

75

Response frrequency (%)

Response frrequency (%)

100

Control
Sham
OVX

50

25

mN

Week 1

16

32

75

16

32

50

*
25

mN

Week 5

OVx Preventive Hormone Replacement Therapy

100
Response frequency (%)
R

Response frequency (%)

R

100

75

50

25

0
1

mN

OVX + placebo
OVX + 17-Estradiol

Week 1

16

32

75

50

16

32

25

mN

Week 5

Control
Sham

Prevention of abdominal mechanical hyperalgesia

(pellets on week 1)

OVx Restorative Hormone Replacement Therapy

50

25

16

32

mN

Response frequency (%)

75

100

100
Response frequency (%)

Response frequency (%)

100

75

50

25

mN

Week 1

Week 5

16

32

75

50

25

16

32

mN

Week 6

OVX + placebo
OVX + 17-Estradiol
Control
Sham

Reversal of abdominal mechanical hyperalgesia

(pellets on week 5)

(Sanoja and Cervero, 2008)

Activation of ERK1/2 in OVX mice (7 weeks post-surgery)

Lumbo-Sacral Spinal Cord

- p-ERK 1/2 (44/42 kDa)

- ERK 1/2 (44/42 kDa) C

OVX

GAPDH (37 kDa) -

C
C

S
S

OVX
OVX

Activation of ERK1/2 in OVX mice (estrogen reversal)

Lumbo-Sacral Spinal Cord

p-ERK 1/2 (44/42 kDa)

ERK 1/2 (44/42 kDa)

Visceral Pain
The most frequent form of clinically relevant pain
Inadequately managed and poorly treated
Mechanistically: an alarm system with widespread motor and
autonomic reactions
Periphery: close relation with visceral function (motility,
secretion, epithelial transport)
CNS: hormonal / metabolic influences slow time course
Animal models of visceral pain should reproduce a functional
process

Whereas acute symptomatic pain serve

the useful purpose of warning, chronic
pain is a malefic force which imposes
severe emotional, physical and economic
stresses on the patient
John J. Bonica

John J. Bonica (1917(1917-1994)

What to do to relieve pain?

- Increase our knowledge: Study pain
- Apply our knowledge: Treat pain
- Create a communication vehicle
between those who study and
those who treat pain

John J. Bonica (1917(1917-1994)

Working together for pain relief throughout the world

www.IASP-pain.org