What is Pelvic Congestion Syndrome (PCS)?

From the Guidelines

Pelvic Congestion Syndrome (PCS) is a chronic condition characterized by pelvic pain caused by enlarged, varicose veins in the pelvis, primarily affecting women of reproductive age, and is thought to result from hormonal influences on the venous system, causing vein wall weakening and subsequent blood pooling. The diagnosis of PCS typically requires pelvic ultrasound or MRI to visualize the dilated veins, as symptoms can mimic other gynecological conditions 1.

Key Characteristics of PCS

• Enlarged, varicose veins in the pelvis
• Pelvic pain
• Hormonal influences on the venous system
• Vein wall weakening and subsequent blood pooling
• Primarily affects women of reproductive age

Diagnosis and Treatment

Treatment of PCS typically begins with non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for pain management, and hormonal treatments such as medroxyprogesterone acetate (30-50mg daily) or combined hormonal contraceptives can help reduce symptoms by suppressing ovarian function and decreasing blood flow to the pelvic veins 1. For patients with severe symptoms not responding to medications, minimally invasive procedures like ovarian vein embolization may be recommended, which blocks blood flow to the affected veins 1. Lifestyle modifications including regular exercise, avoiding prolonged standing, and elevating the legs when possible can help manage symptoms. Pelvic floor physical therapy may also provide relief.

Recent Developments in Treatment

Recent studies have shown that percutaneous endoluminal left renal vein stenting is increasingly performed due to the morbidity associated with surgical techniques 1. Additionally, laparoscopic left ovarian vein surgical ligation has been described as a treatment option for PCS, with complete resolution of symptoms reported in some patients 1.

Importance of Accurate Diagnosis

Accurate diagnosis of PCS is crucial, as symptoms can mimic other gynecological conditions, and treatment should be tailored to the individual patient's needs 1. A comprehensive diagnostic approach, including pelvic ultrasound or MRI, is essential for confirming the presence of dilated veins and guiding treatment decisions.

From the Research

Definition of Pelvic Congestion Syndrome (PCS)

• Pelvic Congestion Syndrome (PCS) is defined as noncyclical pelvic pain or discomfort caused by dilated parauterine, paraovarian, and vaginal veins 2
• It is also characterized by ovarian venous incompetence that may be due to pelvic venous valvular insufficiency, hormonal factors, or mechanical venous obstruction 2
• PCS is a common cause of chronic pelvic pain in women, accounting for 16-31% of cases, and is usually diagnosed in the third and fourth decades of life 3

Symptoms of PCS

• Chronic pelvic pain of more than six months duration with no evidence of inflammatory disease 4
• Pain of variable intensity that is worse in the pre-menstrual period, and is exacerbated by walking, standing, and fatigue 4
• Post coital ache, dysmenorrhea, dyspareunia, bladder irritability, and rectal discomfort are also common symptoms 4
• Patients with PCS may present with a cluster of symptoms related to pelvic venous congestion, including pelvic pain worse on standing, irritable bowel symptoms, vulval varicosities, and lower limb venous pathology 5

Diagnosis of PCS

• Non-invasive imaging such as ultrasound, CT, and MRI are essential in the diagnosis and exclusion of other conditions that cause chronic pelvic pain 4
• Trans-catheter venography remains the gold standard modality for the definitive diagnosis of PCS and is undertaken as an immediate precursor to ovarian vein embolization (OVE) 4
• Transvaginal ultrasound is a non-invasive and sensitive test for PCS 5

Treatment of PCS

• Ovarian vein embolization (OVE) is a safe, minimally invasive, and efficacious treatment for PCS, with reported technical success rates of 96-100% and long-term symptomatic relief in 70-90% of cases 4
• Embolization of pelvic and ovarian veins is a common treatment used currently, although it may be complicated by migration of embolization coils 6
• Other treatments such as hysterectomy combined with oophrectomy, open surgical ligation of ovarian veins, and laparoscopic vein ligation have been used in the past, but are less common now 6