Update on Pelvic Vein Congestion

Introduction:

Pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear and the optimum treatment is uncertain. Development of an evidencebased approach to managing these patients has been limited by the absence of definitive diagnostic criteria.

Epidemiology:

It is difficult to establish the true incidence of PCS, given the lack of definitive diagnostic criteria. It primarily affects multiparous women in the reproductive age group. No cases have been reported in menopausal women. PCS may account for up to 30 percent of patients presenting with chronic pelvic pain in whom no other obvious pathology can be found.

Pathogenesis:

The etiology of PCS is unclear. Multiple investigators have observed gross dilatation, incompetence, and reflux of the ovarian veins in women with PCS and have thus attributed PCS to underlying venous pathology. In this model, anatomic and/or hormonal factors lead to venous insufficiency of the ovarian veins and/or internal iliac veins, resulting in periovarian pelvic varicosities. Tuboovarian varicoceles have been termed the female equivalent of testicular varicocele.

Ovarian vein dilatation, stasis, and/or reflux on pelvic venography are common findings in multiparous premenopausal women, and most of these women are asymptomatic. Why these findings are associated with chronic pelvic pain in some women, but not in others, is unclear. A causal relationship has not been proven, but is supported by limited data showing pain relief upon administration of venoconstrictors or ovarian vein ligation/embolization. Other small studies of women with chronic pelvic pain, venous congestion, and reflux by either Doppler ultrasound and/or venography and no evidence of pelvic pathology at laparoscopy have reported improvement in pain after sclerotherapy, embolization, or venous ligation.

The higher prevalence of PCS in multiparous women may be related to the 50 percent increase in pelvic vein capacity during pregnancy, which may lead to venous incompetence and reflux in the non-pregnant state. The increased frequency of PCS symptoms on the left side may be due to extrinsic compression of the left renal vein between the aorta and superior mesenteric artery (“nutcracker phenomenon;” ie, pelvic congestion, left flank pain, and hematuria), or because valvular incompetence of the ovarian vein due to absent ovarian vein valves is more common on the left. Ovarian vein valves are missing in 15 percent of women on the left side and 6 percent of women on the right and nearly one-half of these women have valvular incompetence on at least one side.The absence of PCS in menopause has been attributed to the decline in estrogen, which acts as a venous dilator. This hypothesis is supported by observations that pharmacologic or surgical induction of a hypoestrogenic state may result in improvement or resolution of symptoms.

Clinical Manifestations:

PCS is characterized by pelvic pain of at least six months duration. It often first manifests during or after a pregnancy, and worsens with subsequent pregnancies. The pain varies in severity, but is usually described as a dull ache or heaviness that increases premenstrually; with prolonged standing, postural changes, walking, or activities that increase intraabdominal pressure; and after intercourse (postcoital ache). It is usually unilateral, but can be bilateral or shift from one side to the other. The patient may also complain of sharp exacerbations of pain, dysmenorrhea, deep dyspareunia, and urinary urgency. Gluteal, vulvar, and/or thigh varices may also be present.

Treatments:

 Invasive treatments for PCS have not been subjected to randomized clinical trials. The efficacy of these therapies is supported only by observational data and case series. The studies generally lack consistency; patients have varied symptoms and lack standardized diagnosis. These reports also lack a control group, involve different venography, embolization and surgical techniques, and fail to provide standardized evaluation of symptoms before and after treatment. The reported technical success rates of embolization for treatment of PCS range from 89 to 100 percent with clinical success rates of 58 to 100 percent over a follow-up period of up to five years. Surgical ligation of the ovarian vein has been associated with improvement in pain in about 75 percent of patients. The effects of hysterectomy are unclear; one study reported improvement after hysterectomy in 75 percent of patients with PCS, while another found no improvement.

References:

  1.  Robinson JC. Chronic pelvic pain.Curr Opin Obstet Gynecol 1993; 5:740–743.
  2. Kim HS, Malhotra AD, Lee ML, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol 2006; 17:289–297.
  3. Richet MA. Traite pratique d’anatomie medico-chirurgicale [Treatise on practical medical-surgical anatomy]. Paris:Balliere et fils, 1857.
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