New Findings About Emotional Brain Changes in Prostatitis: What to do About it

Swiss researchers looking into brain activity in men with prostatitis, chronic pelvic pain syndrome report that in a small group of men there is a reduction in relative gray matter volume in a part of the cortex.

A new article written in the October 2012 Journal of Urology identifies some changes in the anterior cingulate part of the brain in men suffering from prostatitis, chronic pelvic pain syndrome. The anterior cingulate cortex and other related parts of the brain, comprising part of the limbic system, are known to be connected with the perception of pain and emotion. The Swiss researchers’ observations of changes in this area of the brain may support the idea that when one has changes in prostatitis, chronic pelvic pain, the chronic anxiety fed by catastrophic thoughts that the pain will never go away is reflected in some changes in the brain.

That chronic pelvic pain and emotions are intimately connected and probably affect the brain is no surprise to any of us who have been treating chronic pelvic pain over the years. Many of our patients agree that the feelings of helplessness, hopelessness, and fear can be worse than the actual physical pain.

As with all the research that documents certain relationships, the “elephant in the room” type of question, in this case, is if pain and emotions are strong enough to affect the brain in the way the Swiss researchers have recently documented, what does it mean and what can be done about it? Over the years, our answer has been simple: empower patients to reduce or stop their physical pain and help them reduce their emotional distress.

Wise-Anderson Physical Therapy Self-Treatment and Paradoxical Relaxation

In our latest review of data from patients we have seen in the last four years, we discovered—not surprisingly—that when you give patients the ability to reduce their pain, their emotional distress calms down. In the Wise-Anderson Protocol, the two major methods we use are focused on reducing pelvic pain mentally and physically. We have documented (see 2011 articles in the Journal of Urology and the Clinical Journal of Pain) that physical therapy self-treatment in combination with Paradoxical Relaxation significantly reduces pelvic muscle sensitivity/pain. In additional data, we found that this reduction in pain is associated with a significant reduction in emotional distress. More information on treatment here

In future research, it would be interesting to observe whether the reduction or resolution of symptoms of prostatitis and related pelvic pain syndromes, as experienced after doing our protocol for 6 months, reverses the brain changes this recent study found.

Below are articles on the subject of brain changes related to changes in prostatitis, chronic pelvic pain syndromes.

1. Chronic Pelvic Pain Syndrome in Men is Associated with Reduction of Relative Gray Matter Volume in the Anterior Cingulate Cortex Compared to Healthy Controls.

Mordasini L, Weisstanner C, Rummel C, Thalmann GN, Verma RK, Wiest R, Kessler TM.

J Urol. 2012 Oct 18. pii: S0022-5347(12)04500-4. doi: 10.1016/j.juro.2012.08.043.

Source

Department of Urology, University of Bern, Bern, Switzerland.

Abstract

PURPOSE:

Although chronic pelvic pain syndrome impairs the life of millions of people worldwide, the exact pathomechanisms involved remain to be elucidated. As with other chronic pain syndromes, the central nervous system may have an important role in chronic pelvic pain syndrome. Thus, we assessed brain alterations associated with abnormal pain processing in patients with chronic pelvic pain syndrome.

MATERIALS AND METHODS:

Using brain morphology assessment applying structural magnetic resonance imaging, we prospectively investigated a consecutive series of 20 men with refractory chronic pelvic pain syndrome, and compared these patients to 20 gender and age matched healthy controls. Between group differences in relative gray matter volume and the association with bother of chronic pelvic pain syndrome were assessed using whole brain covariate analysis.

RESULTS:

Patients with chronic pelvic pain syndrome had a mean (±SD) age of 40 (±14) years, a mean NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) total score of 28 (±6) and a mean pain subscale of 14 (±3). In patients with chronic pelvic pain syndrome compared to healthy controls there was a significant reduction in relative gray matter volume in the anterior cingulate cortex of the dominant hemisphere. This finding correlated with the NIH-CPSI total score (r = 0.57) and pain subscale (r = 0.51).

CONCLUSIONS:

Reduction in relative gray matter volume in the anterior cingulate cortex and correlation with bother of chronic pelvic pain syndrome suggest an essential role for the anterior cingulate cortex in chronic pelvic pain syndrome. Since this area is a core structure of emotional pain processing, central pathomechanisms of chronic pelvic pain syndrome may be considered a promising therapeutic target and may explain the often unsatisfactory results of treatments focusing on peripheral dysfunction

2. Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain.

Fenton BW.

Med Hypotheses. 2007;69(2):282-6. Epub 2007 Feb 9.

Source

Summa Health System, Department of Obstetrics and Gynecology, MED-2, 525 E Market St., Akron, OH 44303-2090, United States. fentonb@summa-health.org

Abstract

Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment

3. Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome.

Morgan V, Pickens D, Gautam S, Kessler R, Mertz H.

Gut. 2005 May;54(5):601-7.

Source

Department of Radiology and Radiological Scienes, Vanderbilt University, Nashville, TN 37205, USA.

Abstract

BACKGROUND AND AIMS:

Irritable bowel syndrome (IBS) is a disorder of intestinal hypersensitivity and altered motility, exacerbated by stress. Functional magnetic resonance imaging (fMRI) during painful rectal distension in IBS has demonstrated greater activation of the anterior cingulate cortex (ACC), an area relevant to pain and emotions. Tricyclic antidepressants are effective for IBS. The aim of this study was to determine if low dose amitriptyline reduces ACC activation during painful rectal distension in IBS to confer clinical benefits. Secondary aims were to identify other brain regions altered by amitriptyline, and to determine if reductions in cerebral activation are greater during mental stress.

METHODS:

Nineteen women with painful IBS were randomised to amitriptyline 50 mg or placebo for one month and then crossed over to the alternate treatment after washout. Cerebral activation during rectal distension was compared between placebo and amitriptyline groups by fMRI. Distensions were performed alternately during auditory stress and relaxing music.

RESULTS:

Rectal pain induced significant activation of the perigenual ACC, right insula, and right prefrontal cortex. Amitriptyline was associated with reduced pain related cerebral activations in the perigenual ACC and the left posterior parietal cortex, but only during stress.

CONCLUSIONS:

The tricyclic antidepressant amitriptyline reduces brain activation during pain in the perigenual (limbic) anterior cingulated cortex and parietal association cortex. These reductions are only seen during stress. Amitriptyline is likely to work in the central nervous system rather than peripherally to blunt pain and other symptoms exacerbated by stress in IBS.