How is pelvic congestion syndrome managed?

Management of Pelvic Congestion Syndrome

Ovarian vein embolization is the most effective treatment for pelvic congestion syndrome, with studies showing substantial pain relief in approximately 75% of women that is generally sustained over time. 1

Diagnosis and Clinical Features

Pelvic congestion syndrome (PCS) is characterized by:

• Chronic pelvic pain lasting more than six months
• Pain that worsens with standing, walking, or fatigue
• Pain that may intensify during pre-menstrual period
• Associated symptoms including dyspareunia, post-coital ache, dysmenorrhea, bladder irritability, and rectal discomfort 2

Diagnostic imaging should include:

• Transvaginal ultrasound with color and spectral Doppler to document:
  • Engorged periuterine and periovarian veins (≥8 mm)
  • Low-velocity flow
  • Altered flow with Valsalva maneuver
  • Retrograde flow of the ovarian veins 1

Treatment Algorithm

First-Line Approach: Conservative Management

1. Medical therapy options:
   • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management
   • Hormonal agents (may help reduce pelvic congestion)
   • Venoactive drugs/venoprotective agents
   • Compression therapy 3

Second-Line Approach: Interventional Treatment

When conservative management fails to provide adequate symptom relief:

1. Ovarian vein embolization (OVE):

   • Technical success rates of 96-100%
   • Long-term symptomatic relief in 70-90% of cases
   • Low complication rates 2
   • Can be performed as an outpatient procedure under local anesthesia 4
   • Techniques include:
     • Coil embolization
     • Sclerotherapy (using agents like 3% sodium tetradecyl sulfate)
     • Combination approaches 1

2. Internal iliac vein embolization:

   • Often performed in addition to ovarian vein embolization
   • Safe and effective in treating pelvic venous insufficiency 1

Third-Line Approach: Surgical Options

When endovascular treatments fail or are contraindicated:

1. Laparoscopic ovarian vein ligation:

   • Complete resolution of symptoms has been reported in selected cases 1

2. Left renal vein stenting:

   • For cases related to nutcracker syndrome
   • Less invasive alternative to open surgical approaches 1

Special Considerations

• Repeat interventions: If initial embolization provides insufficient relief, a second procedure may be considered, though evidence for efficacy is contradictory 1

• Post-procedure symptoms: Transient pain is common following foam embolization, but typically resolves quickly 1, 4

• Complications: Risk of coil migration is less than 2% 1

• Follow-up: Ultrasound follow-up at 6-12 months shows reduction in periovarian varicosities, with persistent symptoms more likely in women with pelvic varicosities measuring over 5 mm 4

Pitfalls and Caveats

1. Diagnostic challenges: PCS is often underdiagnosed, leading to unnecessary procedures and delayed treatment 2

2. Multidisciplinary approach: Due to the complex nature of chronic pelvic pain, involvement of gynecologists, interventional radiologists, pain specialists, and other relevant specialists is crucial 2

3. Exclusion of other causes: Before diagnosing PCS, other causes of chronic pelvic pain must be excluded through appropriate imaging and clinical evaluation 1

4. Patient selection: Careful patient selection for interventional procedures is essential to optimize outcomes 5

5. Evidence limitations: Despite good clinical outcomes, there is a lack of prospective, multicenter randomized controlled trials for both investigation and management of PCS 2