Physiology of Visceral Pain

Pain involving thoracic, abdominal, or pelvic organs is a common cause for physician consultations, including one-third of chronic pain patients who report that visceral organs contribute to their suffering. Chronic visceral pain conditions are typically difficult to manage effectively, largely because visceral sensory mechanisms and factors that contribute to the pathogenesis of visceral pain are poorly understood. Mechanistic understanding is particularly problematic in "functional" visceral diseases where there is no apparent pathology and pain typically is the principal complaint. We review here the anatomical organization of the visceral sensory innervation that distinguishes the viscera from innervation of all other tissues in the body. The viscera are innervated by two nerves that share overlapping functions, but also possess notably distinct functions. Additionally, the visceral innervation is sparse relative to the sensory innervation of other tissues. Accordingly, visceral sensations tend to be diffuse in character, are typically referred to nonvisceral somatic structures and thus are difficult to localize. Early arguments about whether the viscera were innervated ("sensate") and later, whether innervated by nociceptors, were resolved by advances reviewed here in the anatomical and functional attributes of receptive endings in viscera that contribute to visceral pain (i.e., visceral nociceptors). Importantly, the contribution of plasticity (i.e., sensitization) of peripheral and central visceral nociceptive mechanisms is considered in the context of persistent, chronic visceral pain conditions. The review concludes with an overview of the functional anatomy of visceral pain processing. © 2016 American Physiological Society. Compr Physiol 6:1609-1633, 2016.