Pelvic congestion syndrome: the role of interventional radiology in the treatment of chronic pelvic pain

Abstract

Chronic pelvic pain is a common problem for female patients and is defined as pain that has been present for 6 months or more. Chronic pelvic pain with associated ovarian vein varicosities is termed pelvic congestion syndrome (PCS) and is an important but under-diagnosed condition. The aetiology of pelvic varicosities is reflux of blood in the ovarian veins due to the absence of functioning valves, resulting in retrograde blood flow and eventual venous dilatation. The cardinal presenting symptom of PCS is pelvic pain, usually described as a dull ache, without evidence of inflammatory disease. Clinical signs may include vulval varicosities extending on to the medial thigh and long saphenous territory as well as tenderness on deep palpation at the ovarian point; however, such signs are not always present. Non-invasive imaging (ultrasound, CT and magnetic resonance venography) plays a central role in establishing the diagnosis, excluding alternative causes of pelvic pain and providing a road map for novel minimally invasive treatment options that are now available. Day-case percutaneous-directed venous embolisation is now accepted as a valuable treatment option for PCS with promising results from early clinical trials and is fast becoming the first-line treatment option for this condition. This paper aims to raise awareness of PCS among clinicians and reviews the pathogenesis, imaging assessment and minimally invasive treatment options that are now available.

Ovarian vein diameters measured by MDCT in women without evidence of pelvic congestion syndrome

“…The etiology of secondary PCS is related to underlying abnormalities, resulting in increased pressure in the abdominal and pelvic veins, which transmits retrograde to the pelvic venous system resulting in the pelvic congestion (11)(12). Although there are no established criteria for the cross-sectional imaging diagnosis of PCS, relatively arbitrary diagnostic criteria are tortuous and dilated ovarian veins, reflux in ovarian veins, congested parauterine and paraovarian venous plexus, and presence of pelvic varicose veins (11,13,14). Ovarian vein dilatation with diameters greater than 8 mm on the left side and 4 mm on the right side on multidetector computed tomography (MDCT) are defined as clearly abnormal (11), but this diagnostic criterion is not universally accepted (15).…”

Síndrome da Congestão Venosa Pélvica e resultados do tratamento endovascular: série de casos

“…In these circumstances treatment of the left gonadal vein only is acceptable, since with these anatomic findings it is unlikely that the right gonadal vein is responsible for the symptoms. 6 None of the patients described here suffered serious complications. Mild intercurrent conditions observed were hematoma of the puncture site and postoperative abdominal pains, which did not affect the final results.…”

“…In general, the pain worsens during the perimenstrual period and with increased intra-abdominal pressure, generally accompanied by dyspareunia and postcoital discomfort, urinary symptoms (secondary to varicose veins in the bladder wall) and feelings of heaviness in the pelvis and legs. 6 Physical examination may reveal varicose veins involving the vulva, perineal area and buttocks, and pain if the cervix of the uterus is moved. 3 Well-directed patient history and physical examination should lead to a diagnostic suspicion, which should then be confirmed with supplementary examinations.…”

Pelvic Congestion Syndrome Initially Detected by Contrast-Enhanced F-18 FDG-PET/CT

“…The causes of ovarian varicoceles are multifactorial, involving both mechanical and hormonal factors. Dilatation of the ovarian veins can result in vascular incompetence and retrograde blood flow [3].On either CT or magnetic resonance (MR) imaging studies, pelvic varices in PCS appear as dilated, tortuous, enhancing tubular structures near the ovaries and uterus [4]. In addition, the extension of varices to the broad ligament and paravaginal venous plexus can be appreciated [5].…”

“…On either CT or magnetic resonance (MR) imaging studies, pelvic varices in PCS appear as dilated, tortuous, enhancing tubular structures near the ovaries and uterus [4]. In addition, the extension of varices to the broad ligament and paravaginal venous plexus can be appreciated [5].…”