Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options

Abstract

Pelvic venous congestion syndrome (PVCS) is a common, but underdiagnosed, cause of chronic pelvic pain (CPP) in women.PVCS occurs usually, but not exclusively, in multiparous women. It is characterized by chronic pelvic pain of more than six months duration with no evidence of inflammatory disease.The patients present to general practitioners, gynaecologists, vascular specialists, pain specialists, gastroenterologists and psychiatrists. Pain of variable intensity occurs at any time but is worse in the pre-menstrual period, and is exacerbated by walking, standing, and fatigue. Post coital ache, dysmenorrhea, dyspareunia, bladder irritability and rectal discomfort are also common. Under-diagnosis of this condition can lead to anxiety and depression.A multidisciplinary approach in the investigation and management of these women is vital.Non-invasive imaging (US, CT, MRI) are essential in the diagnosis and exclusion of other conditions that cause CPP as well in the definitive diagnosis of PVCS. Trans-catheter venography remains the gold standard modality for the definitive diagnosis and is undertaken as an immediate precursor to ovarian vein embolization (OVE). Conservative, medical and surgical management strategies have been reported but have been superseded by OVE, which has a reported technical success rates of 96-100%, low complication rates and long-term symptomatic relief in between 70-90% of cases.The condition, described in this paper as PVCS, is referred to by a wide variety of other terms in the literature, a cause of confusion.There is a significant body of literature describing the syndrome and the excellent outcomes following OVE however the lack of prospective, multicentre randomized controlled trials for both investigation and management of PVCS is a significant barrier to the complete acceptance of both the existence, investigation and management of the condition.

Keywords: Chronic pelvic pain; Embolization; Embolotherapy; Ovarian Vein Embolization; Ovarian varices; Pelvic congestion syndrome; Pelvic varices; Pelvic venous insufficiency.

Fig. 1

Symptoms-Varices-Pathophysiology (SVP) classification (Meissner et al 2021) Reproduced under Creative Commons Licence. Images Acknowledged to Mesa Schumacher 2021)

Fig. 2

Normal pelvic and ovarian venous anatomy. The rich uterine venous plexus (UVP) drains via the right and left uterine veins (RUV, LUV) into the internal iliac veins (RIIV, LIIV) which anastomose with the external iliac veins (EIV) to become the common iliac veins (CIV). The UVP anastomoses superiorly with the ovarian venous plexus (OVP) bilaterally which drain into the ovarian veins. The right ovarian vein (ROV) drains into the inferior vena cava (IVC) and the left ovarian vein (LOV) drains into the left renal (LRV). (Image courtesy S Boland)

Fig. 3

Trans-vaginal and Doppler ultrasound studies in a multiparous woman presenting with bilateral lower limb varicosities and pelvic pain. Pelvic venous congestion with left ovarian vein diameter of 9.1mm (A), and right ovarian vein diameter of 10mm (C) (red arrows), both diameters increased with Valsalva manoeuvre. Left (B) and right (D) ovarian vein Doppler studies Average flow 0.8cm/sec

Fig. 4

MRI/MRv The left ovarian vein (long arrow) is clearly identified filling early and extends down into the pelvis where small varices (arrow head) are filled on the left side with a crossover of venous flow to the right side and subsequent multiple varicosities are identified in the right upper thigh on this TR IC K S study

Fig. 5

Left ovarian venogram demonstrating left ovarian vein (LOV) dilatation with dilated pelvic and para uterine veins. The left ovarian vein was treated with 3% STS and coil embolization. The right ovarian vein (ROV) did not appear dilated and was treated with coil embolization

Fig. 6

6a Left Ovarian venography with Valsalva The left ovarian venogram (long arrow on left) in a multiparous woman, shows significant venous dilatation with extensive varicosities (arrow heads) and reflux across the midline to the right ovarian vein (long arrow on right). 6b Right ovarian venography following left ovarian vein coil embolization (arrow heads). The ROV (long arrow) was embolized with coils