Pelvic congestion syndrome

Abstract

Patients with pelvic congestion syndrome present with otherwise unexplained chronic pelvic pain that has been present for greater than 6 months, and anatomic findings that include pelvic venous insufficiency and pelvic varicosities. It remains an underdiagnosed explanation for pelvic pain in young, premenopausal, usually multiparous females. Symptoms include noncyclical, positional lower back, pelvic and upper thigh pain, dyspareunia, and prolonged postcoital discomfort. Symptoms worsen throughout the day and are exacerbated by activity or prolonged standing. Examination may reveal ovarian tenderness and unusual varicosities-vulvoperineal, posterior thigh, and gluteal. Diagnosis is suspected by clinical history and imaging that demonstrates pelvic varicosities. Venography is usually necessary to confirm ovarian vein reflux, although transvaginal ultrasound may be useful in documenting this finding. Endovascular therapy has been validated by several large patient series with long-term follow-up using standardized pain assessment surveys. Embolization has been shown to be significantly more effective than surgical therapy in improving symptoms in patients who fail hormonal therapy. Although there has been variation in approaches between investigators, the goal is elimination of ovarian vein reflux with or without direct sclerosis of enlarged pelvic varicosities. Symptom reduction is seen in 70 to 90% of the treated females despite technical variation.

Keywords: female varicocele; nutcracker syndrome; pelvic congestion syndrome; pelvic pain syndrome; pelvic vascular congestion; pelvic vein incompetence; vulvar varices.

Figure 1

(A and B) Transvaginal ultrasound demonstrating dilated paraovarian (uterineovarian and salpingo ovarian) veins. Color Doppler examination revealing augmentation of blood flow with Valsalva maneuver. (C) Renal venography demonstrates ovarian vein insufficiency during Valsalva. The ovarian vein is dilated (arrow). (D) Selective ovarian venography demonstrates dilated paraovarian veins with faint filling of uterine veins crossing the midline (arrow). (E) After sodium tetradecyl sulfate foam sclerotherapy, there is stagnant flow in bilateral paraovarian veins. (F) Layed-out coils in the left ovarian vein. (G) Selective right ovarian venography demonstrates dilated right paraovarian veins prior to sclerotherapy and coil occlusion of the left ovarian vein. (H) Transvaginal ultrasound following treatment demonstrating markedly diminished flow in the paraovarian veins (compare with Fig. 1B).

Figure 2

(A) Computed tomographic demonstration of renal vein compression (arrowhead) between the anterior superior mesenteric artery and the aorta, with upstream renal vein dilation. (B) Renal venography demonstrating ovarian vein reflux into a dilated left ovarian vein (arrow). (C) Selective ovarian venography demonstrating large paraovarian veins. Dilated uterine veins cross the midline to fill right paraovarian veins that drain into the right internal iliac vein (arrow). (D) Coil occlusion of the left ovarian vein after sclerotherapy of the paraovarian veins. (E and F) Renal venography at 4 months following the original procedure demonstrates reflux into a dilated vein that runs parallel to the coil pack and fills left paraovarian veins. (G) Renal venography following sclerotherapy of the recanalized ovarian vein and coil occlusion. A 14 mm by 4 cm self-expanding stent has been placed across the renal compression (arrow). No further reflux is demonstrated.

Figure 3

(A) Selective left ovarian venography fills paraovarian and vulvar varices that cross the midline and drain through the right internal iliac vein. (B) Direct puncture and injection of a left vulvar varicosity to plan sclerotherapy injection volume.