“If only I had found out earlier” is an all-too-common lament made by patients presenting with often years of “investigated” chronic pelvic pain (CPP) when the diagnosis of Pelvic Congestion Syndrome (PCS) is made.
CPP affects between 15-43% of 18-50 females worldwide, comprising 10-20% of all outpatient gynaecologic visits and up to 40% of gynaecologic laparoscopies. CPP has significant physical, emotional and quality of life implications. PCS is estimated to account for 30-40% of CPP.
CPP is a challenging, often multifactorial diagnosis with multiple possible differential (mainly gynaecological) diagnoses. Over a third of patients following investigation are left with chronic pain with mild arguably asymptomatic gynaecological pathology or labelled as “chronic pain patients”.
PCS in simple terms is the development of ‘varicose veins’ in the pelvis. It can be associated with intermittent, often cyclical but sometimes persistent chronic abdominal and pelvic pain lasting over six months. Common in women of reproductive age (parous more than nulliparous), PCS is also associated with secondary venous complications after menopause.
Pelvic congestion syndrome symptoms inside the pelvis include pelvic pain, ‘heaviness’ or ‘dragging’ sensation to pelvis or perineum and genitals, bloating, dyspareunia, lower abdominal pain, stress incontinence and irritable bowel-like symptoms.
Outside the pelvis there may be varicose veins (vulva, groin, buttock, lower limb), leg swelling or heaviness and chronic venous symptoms (e.g. eczema pigmentation). Symptoms can be variable in nature and position and are often worsened by menstrual periods due to hormonal influences on pelvic venous dilatation and worsened by increased abdominal pressure (e.g. lifting, prolonged standing).
The primary pathophysiology is associated with incompetence of the ovarian (uni or bilateral, left more than right side) and pelvic vein plexus. This does not affect the localisation of patient symptoms.
In the vast majority of cases this is associated with ovarian vein incompetence. However, in some cases it can be associated with internal iliac vein incompetence. This incompetence can be congenital (nulliparous women), but pregnancy is strongly associated with secondary incompetence.
This incompetence results in pelvic venous hypertension and dilated congested pelvic varicosities involving the uterus, rectum, bladder, vagina, and secondary lower limb pressurisation causing inflammation and the constellation of PCS symptoms.
Rarely, pelvic venous hypertension can be associated with extrinsic venous compression caused by a May-Thurner Syndrome (iliac vein compression between iliac artery and spine) or a Nutcracker Syndrome (renal vein compression between aorta and superior mesenteric artery).
Specialist pelvic ultrasound utilising transvaginal imaging has been demonstrated as the most sensitive for identifying pelvic varicosities and dilated ovarian veins to suggest PCS as well as to exclude other primary gynaecological pathologies. In CPP or suspected PCS, a pelvic transabdominal and transvaginal ultrasound should be undertaken. CT or MR venography have some role but should not be used initially due to a low specificity. In most cases it should be utilised as interventional planning imaging or to assess for compressive syndromes.
While medical treatment options exist, the mainstay and gold-standard treatment in ultrasound confirmed or clinically suspected PCS is minimally invasive interventional abdominal venography and endovascular ovarian vein embolisation (OVE). This is an extremely low-risk, percutaneous day-case endovascular procedure under local anaesthesia and sedation in which the abdominal and pelvic venous anatomy is definitively assessed and treated in the same procedure if found to be abnormal.
In the vast majority of cases this consists of bilateral or unilateral ovarian vein coil embolisation to occlude the incompetent ovarian veins depressurising the pelvic venous hypertension and varicosities. Adjuvant techniques such as intravascular ultrasound (IVUS) or DYNA CT (interventional CT venography) can also be used to assess for rare causes of PCS (e.g., May-Thurner or Nutcracker syndromes) which may require additional intervention such as stenting.
OVE is associated with a reported 68.2-100% improvement of symptoms with a reported significant reduction in symptoms on Visual Analogue Scale (VAS) of 5.7. The complication rate is extremely low at 0.85% of which all were minor such as groin haematomas.
Recurrent symptoms post-OVE are reported at approximately 2%, meaning very low re-intervention rates. Improvements of symptoms were reported over one to 90 days. The commonly used platinum coils are benign and inert. The other concern often raised regards fertility post-OVE. Evidence suggests management of PCS is likely associated with improved fertility and no reported adverse effects to fertility have been documented.
Key messages
- PCS is an underdiagnosed, underrecognised, underappreciated, and often ignored common cause of CPP
- PCS is relatively easily diagnosed and has a low risk and successful treatment
- Better awareness and clinical suspicion for the specific symptomatology of PCS may speed up PCS diagnosis and treatment.
– References available on request
Author competing interests – nil