How is pelvic venous congestion managed?

Management of Pelvic Venous Congestion Syndrome

Ovarian vein embolization is the first-line treatment for pelvic venous congestion syndrome, with studies showing substantial pain relief in approximately 75% of women with sustained improvement over time. 1

Diagnostic Approach

Diagnosis of pelvic venous congestion syndrome (PVCS) requires a targeted approach:

• Clinical presentation: Chronic pelvic pain (>6 months), worse when standing, premenstrual exacerbation, post-coital ache, dyspareunia, and bladder irritability 2
• Initial imaging: Ultrasound, CT, or MRI to identify pelvic venous engorgement and exclude other causes of chronic pelvic pain 3
• Definitive diagnosis: Venography remains the gold standard and is typically performed immediately before treatment 2

For patients with suspected nonthrombotic iliac vein lesions (NIVL) contributing to PVCS:

• Invasive diagnosis with complementary venography and intravascular ultrasound (IVUS) is recommended
• Dynamic IVUS evaluation with breath hold and maneuvers that increase intra-abdominal pressure helps distinguish pathological fixed lesions from dynamic compressions 1

Treatment Algorithm

First-Line Treatment: Ovarian Vein Embolization

Ovarian vein embolization is the most effective treatment for PVCS with:

• Technical success rates of 96-100% 2
• Substantial pain relief in 75% of women 1
• Long-term symptomatic relief in 70-90% of cases 2
• Low complication rates (typically <9%) 1

Common embolization materials include:

• Coils
• Sclerosants (sodium tetradecyl sulfate or polidocanol)
• Combination approaches 1

Treatment for Complex Cases

For patients with combined pathology:

1. PVCS with gonadal vein reflux and NIVL:

   • Combined or staged approach with iliac vein stent placement and ovarian vein embolization provides better symptom relief than ovarian vein embolization alone 1

2. PVCS due to nutcracker syndrome (left renal vein compression):

   • Percutaneous endoluminal left renal vein stenting is preferred over surgical approaches due to lower morbidity 1
   • Limited studies show remission of pelvic venous symptoms with left renal vein stenting 1

3. PVCS with internal iliac vein involvement:

   • Internal iliac vein embolization (in addition to ovarian vein embolization) is safe and effective 1

NIVL Treatment Criteria

For patients with NIVL contributing to PVCS:

• Intervention is recommended only with >50% area reduction or >61% diameter stenosis on IVUS 1
• Intervention below these thresholds is not recommended 1

Complications and Management

Post-embolization complications may include:

• Transient abdominal discomfort (up to 14.8% of patients) - usually self-limited or treated with analgesics 1
• Colic-like pain - typically resolves spontaneously within 5 minutes 1
• Less common: thrombophlebitis, nontarget embolization, recurrent varices, and stroke-related paradoxical emboli 1

Special Considerations

• Repeat procedures: Evidence is mixed regarding second embolization procedures. If no improvement occurs after initial embolization, a second procedure may not be effective 1
• Pregnancy-related recurrence: Repeat embolization has been shown to eliminate recurrent reflux 1
• Lower extremity varicosities: While embolization is effective for pelvic symptoms, there is limited evidence supporting its use specifically for lower extremity pelvic-origin varicose veins 1

Pitfalls to Avoid

1. Misdiagnosis: PVCS is commonly underdiagnosed, leading to anxiety and depression in affected women 2
2. Incomplete evaluation: Failing to exclude other causes of chronic pelvic pain before attributing symptoms to PVCS
3. Inadequate imaging: Relying solely on venography thresholds for NIVL diagnosis is less well established than using IVUS 1
4. Treating dynamic compressions: Dynamic compressions that vary with maneuvers are less likely to be pathological than fixed lesions 1
5. Overlooking combined pathology: Failing to address both reflux and obstruction when both are present 1