From the Guidelines
For investigating pelvic congestion syndrome, I recommend ordering a contrast-enhanced CT of the abdomen and pelvis with venous phase imaging. This recommendation is based on the most recent evidence from the American College of Radiology, which suggests that contrast-enhanced CT can demonstrate engorged periuterine and periovarian veins, venous anatomic variants, and occasional compression of the left renal vein resulting in asymmetric left-sided pelvic varicosities 1.
When ordering the CT scan, it is essential to include both arterial and venous phases, with particular attention to the venous phase to visualize pelvic varices. The patient should receive intravenous contrast with a delay timed to capture the venous filling (typically 60-90 seconds after contrast administration) 1. The scan should extend from the diaphragm to the symphysis pubis to evaluate the ovarian veins from their origin to their drainage points.
Some key considerations when ordering the CT scan include:
- Prior to the scan, the patient should fast for 4-6 hours but remain well-hydrated
- The radiation exposure from CT is a consideration, particularly in younger women of reproductive age
- While CT can identify dilated pelvic veins, MRI or transvaginal ultrasound with Doppler may provide better soft tissue contrast and functional information about blood flow 1
- CT is valuable because it can simultaneously assess for other potential causes of pelvic pain and evaluate for anatomical variants like nutcracker syndrome or May-Thurner syndrome that may contribute to pelvic venous congestion 1
It's also important to note that the evidence from 1 supports the use of contrast-enhanced CT of the pelvis to demonstrate engorged periuterine and periovarian veins, although their drainage into the renal vein or cava will not be evaluated without CT coverage of the abdomen. However, the most recent and highest quality study 1 recommends a contrast-enhanced CT of the abdomen and pelvis, which provides a more comprehensive evaluation of the pelvic veins and their drainage.
From the FDA Drug Label
Intra-arterial Procedures ... Intravenous Procedures ( 1. 2) Adults and pediatric patients 12 years of age and over Computed tomography (CT) imaging head and body (270 mg Iodine/mL and 320 mg Iodine/mL).
To investigate the possibility of pelvic congestion syndrome, a Contrast-Enhanced CT of the pelvis should be ordered. The specific contrast agent and dosage will depend on various factors, including patient age, weight, and kidney function.
- Iodixanol injection may be used for CT imaging of the body, including the pelvis, at a concentration of 270 mg Iodine/mL or 320 mg Iodine/mL 2. However, the decision to use contrast and the specific protocol should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.
From the Research
Diagnostic Imaging for Pelvic Congestion Syndrome
To investigate the possibility of pelvic congestion syndrome, the following contrasted CT scans can be ordered:
- Contrast-enhanced CT scan of the abdomen and pelvis to evaluate the ovarian veins and pelvic varices 3
- CT venography to assess the gonadal vein dilatation and parauterine varices 4
Key Features to Look for in CT Scans
When interpreting the CT scans, look for the following key features:
- Dilatation of the ovarian veins (> 8 mm in diameter) 3
- Presence of parauterine varices 3, 4
- Reflux or obstruction of the gonadal, gluteal, or periuterine veins 5
- Compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta (nutcracker syndrome) 5
Additional Imaging Modalities
In addition to CT scans, other imaging modalities that can be used to diagnose pelvic congestion syndrome include: