Hypothesis / aims of study
Patients affected by urologic chronic pelvic pain (UCPP) can present with chronic overlapping pain conditions (COPCs), in which pain affects both pelvic and non-pelvic regions of the body. [1] Among COPCs, fibromyalgia, vulvodynia, temporomandibular disorder, chronic fatigue syndrome, irritable bowel syndrome (IBS), gastro-oesophageal reflux disease, are the most frequently reported. In these conditions, great catastrophizing and negative effects on cognitive functioning and well-being can be observed.
Resilience allows patients to rebound from and to positively adapt to significant stressful events as in the case of chronic diseases and painful conditions. [2] Patients’ resilience has been investigated in cancer and in non-cancer chronic painful conditions, such as fibromyalgia, rheumatoid arthritis, systemic lupus erythematous, musculoskeletal pain, but currently, no information exist on resilience in UCPP patients, and specifically in those presenting with COPCs. We investigated resilience in patients affected by UCPP and the relationships with pain severity and distribution, catastrophizing and psychological distress.
Study design, materials and methods
A pilot study was performed in 33 females and 15 males with UCPP who were regularly followed on an outpatient basis at three expert urology departments. Sociodemographic characteristics (age, education, marital status, employment) and clinical data were collected in a clinical setting by in-person interviews at the three out-patient urology clinic departments. Patients were classified with a pain body map as being affected by pelvic pain only (PP only), pelvic pain and beyond the pelvis and widespread pain (WP). The presence of COPCs was also assessed using the Complex Multiple Symptoms Inventory. Patients underwent the recording of the Pain Numerical Rating Scale (PNRS) to score both pelvic and non-pelvic pain intensity, and the Visual Analog Scale (VAS) to study the impact of urinary symptoms on quality of life (QoL; 0=no bother, 10=worst bother). Furthermore, they were asked to complete the following, self-administered, questionnaires: Pain Catastrophizing Scale (PCS), Depression Anxiety and Stress Scale ‐ short version (DASS ‐21) and 14 item- Resilience scale (RS-14). RS-14 is a measure of resilience with intrinsic properties highlighting individuals’ positive psychological prerogatives rather than deficiencies; it includes a 7-point rating (1= strongly disagree; 7= strongly agree) with scores ranging from 14 to 98. Scores < 56 denote very poor resilience, scores between 57 and 64 indicate low resilience, scores between 65 and 73 indicate resilience levels on the low end, scores between 74 and 81 indicate moderate resilience, scores between 82 and 90 a moderately high resilience and scores > 91 indicate high resilience levels.
Results
All patients were under a multimodal treatment regimen based on the UPOINT system, including antimuscarinics, mirabegron, alpha ‐blockers, antidepressants, anxiolytics, pregabalin, palmitoylethanolamide/polydatin, pelvic-floor muscle exercises, applied in different combination modalities. Patients’ demographics and characteristics of pain and COPCs are shown in Fig. 1.
Scores of PNRS, VAS, Pain catastrophizing Scale, Depression, Anxiety Stress Scale and 14-item Resilience Scale are showed in Fig. 2.
Overall, very low resilience scores were detected in both patients with PP only and WP, but they were significantly more affected in patients with WP. We could observe high levels of catastrophizing in both sub-groups of patients, but those with WP, and particularly females, were significantly more catastrophizing than patients with PP only. Patients with WP were significantly more affected by general distress as compared to those with PP only. In PP only subgroup, males were affected by greater anxiety as compared to female; females with WP showed significantly higher levels of depression, anxiety, stress and general distress as compared to all patients with PP only.
Interpretation of results
While it is known that UCPP patients demonstrate catastrophizing beliefs about pain, especially when they show multiple comorbid conditions, and high rates of mood disorders and general distress, currently there are no consistent information about resilience in chronic pelvic pain. Resilience is not only a personality’ trait but it involves specific neurobiological changes, such as modifications in the cerebral content of neurotransmitters, increased and prolonged blood levels of cortisol and glucocorticoids, increased levels of cytokines with consequent inflammation and atrophy in different areas of the CNS. In pain medicine resilience can be considered as the “capacity to adapt successfully to disturbances that threaten a patient’s viability, function or development". Indeed, resilient individuals, who present with higher levels of pain acceptance, have been observed to show reduced catastrophizing and limited emotional distress.
In the present pilot study very low resilience levels in UCPP patients were detected, particularly in those presenting with WP and COPCs and, overall, in female gender and in patients with greater catastrophizing. Although there is no consensus on the causes of WP and COPCs, it is generally retained they can be the result of central sensitization, with consequent, abnormal plasticity in several brain regions. [3] It is possible to hypothesize that also in our UCPP patients, and particularly in those with WP, inefficient neural processing against the stressful event represented by their wider, chronic painful condition, may be the substrate of poor ability to adapt to pain, higher catastrophizing and distress accompanied by marked mood disorders.