Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment

Abstract

Pelvic venous disorder (PeVD) is a term that encompasses all the interrelated causes of chronic pelvic pain (CPP) and perineal/lower extremity varicose veins of pelvic venous origin historically known as nutcracker syndrome, pelvic congestion syndrome, and May-Thurner syndrome, resulting in a more precise diagnosis that accounts for the underlying pathophysiology and anatomy. PeVD manifests as CPP with associated vulvar and lower-extremity varicosities, left flank pain and hematuria, and lower extremity pain and swelling secondary to obstruction or reflux in the left renal, ovarian, or iliac veins. This article will focus specifically on the most current nomenclature, evaluation, and management of CPP of venous origin.

Keywords: embolization; interventional radiology; pelvic pain; pelvic venous disease; sclerotherapy; women's health.

Fig. 1

The SVP classification system applies to anatomic Zones 1–3 while the CEAP classification system applies to Zone 4. Zone 1 (light green) encompasses the left renal hilum venous reservoir; venous hypertension in this reservoir is associated with renal symptoms of venous origin (flank pain, hematuria, etc.). When severe enough, venous hypertension in the left renal hilum can spill over into the pelvic venous reservoir (Zone 2, pink) via reflux into the left ovarian vein. Zone 2 encompasses the pelvic venous reservoir (ovarian veins, internal iliac veins, and pelvic venous plexus) and venous insufficiency in this reservoir is classically associated with symptoms of chronic pelvic pain of venous origin. Zone 3 (light blue) encompasses the pelvic-origin extrapelvic venous reservoir, where venous insufficiency results in vulvar and upper thigh varices due to reflux in pelvic-origin extrapelvic veins through pelvic escape points. Zone 4—yellow.

Fig. 2

Arterial phase image on time-resolved MR angiography demonstrates retrograde flow in an enlarged left ovarian vein (arrow) and opacification of prominent paraovarian varices (arrowhead).

Fig. 3

Venous phase image on time-resolved MR angiography demonstrates a dilated left ovarian vein (large solid arrow) with numerous bilateral utero-ovarian varices, cross pelvic collaterals (arrowhead), and outflow via the left internal iliac (open arrow) and right ovarian veins (small solid arrows), which demonstrate normal antegrade flow.

Fig. 4

Catheter venography with injection from the left renal hilum demonstrates reflux into the dilated left ovarian vein (arrow) consistent with venous incompetence.

Fig. 5

Digital subtraction angiography from the peripheral left ovarian vein demonstrates numerous left utero-ovarian varicosities (arrow) and cross pelvic collaterals opacifying right utero-ovarian varicosities (arrowhead).

Fig. 6

Postembolization venography from the left renal hilum demonstrates complete occlusion of the left ovarian vein (arrow).