What is pelvic congestion syndrome?

Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS) is a disorder characterized by chronic pelvic pain caused by dilation, engorgement, and reflux of pelvic veins, primarily affecting premenopausal women and often resolving after menopause due to decreased estrogen levels. 1

Clinical Presentation

• Key symptoms:

  • Chronic pelvic pain (>6 months duration)
  • Pain worsens with:
    • Prolonged standing
    • Walking
    • Fatigue
    • Pre-menstrual period
    • Sexual intercourse
  • Associated symptoms:
    • Post-coital ache
    • Dysmenorrhea
    • Dyspareunia
    • Bladder irritability
    • Rectal discomfort 2

• Demographic factors:

  • Most common in premenopausal women
  • Often multiparous
  • Symptoms frequently resolve after menopause due to decreased estrogen levels 1, 3

Pathophysiology

PCS likely has a multifactorial etiology involving:

• Valvular insufficiency in ovarian and pelvic veins
• Venous obstruction (e.g., nutcracker syndrome, May-Thurner syndrome)
• Hormonal factors (estrogen increases venous distensibility)
• Genetic predisposition
• Anatomical abnormalities
• Damage to vein walls 4

Diagnostic Approach

Imaging Studies

1. Ultrasound with Doppler (first-line):

   • Documents engorged periuterine and periovarian veins (>8mm)
   • Evaluates low-velocity flow and altered flow with Valsalva maneuver
   • Assesses retrograde (caudal) flow of ovarian veins
   • Identifies connections between engorged pelvic veins and myometrial arcuate veins 5, 1

2. MRI/MR Angiography:

   • Problem-solving examination when ultrasound is inconclusive
   • Diagnostic performance comparable to conventional venography
   • Can demonstrate pelvic varices and ovarian vein reflux 1, 6

3. CT with contrast:

   • Shows engorged periuterine and periovarian veins
   • Identifies venous anatomic variants and compression of left renal vein
   • Less valuable for dynamic flow information 5, 1

4. Venography with IVUS (gold standard):

   • Definitive diagnosis
   • Dynamic IVUS evaluation should include breath hold and maneuvers that increase intra-abdominal pressure
   • Thresholds of >50% area reduction or >61% diameter stenosis on IVUS correlate with symptom improvement following treatment 1, 2

Differential Diagnosis

Important to rule out other causes of chronic pelvic pain:

• Chronic pelvic inflammatory disease
• Endometriosis
• Adhesive disease
• Hydrosalpinx or pyosalpinx
• Interstitial cystitis/bladder pain syndrome
• Musculoskeletal disorders 5, 1

Treatment Algorithm

1. Conservative Management (First-Line)

• Lifestyle modifications:

  • Avoid prolonged standing
  • Regular appropriate exercise
  • Weight management
  • Application of heat or cold over painful areas
  • Pelvic floor muscle relaxation techniques 1

• Dietary changes:

  • Identify and avoid specific foods that worsen symptoms using elimination diet approach 1

• Stress management:

  • Meditation
  • Imagery techniques
  • Other coping strategies 1

2. Pharmacological Management

• Venoactive agents and ergot alkaloid derivatives 1
• Amitriptyline:
  • Start at low doses (10 mg)
  • Titrate gradually to 75-100 mg if tolerated
  • Monitor for side effects (sedation, drowsiness, nausea) 1
• Cimetidine for pain management 1
• Non-opioid pain management options should be prioritized 1

3. Interventional Treatments (For Persistent Symptoms)

• Ovarian vein embolization (OVE):

  • First-line interventional treatment
  • Technical success rates: 96-100%
  • Symptomatic relief: 70-90% of cases 1, 2, 7

• Internal iliac vein embolization:

  • Often performed with ovarian vein embolization
  • Safe and effective for treating pelvic venous insufficiency 1

• Left renal vein stenting:

  • For cases related to nutcracker syndrome 1

• Endovascular stenting:

  • For nonthrombotic iliac vein lesions (NIVL) associated with PCS 1

• Laparoscopic ovarian vein ligation:

  • Alternative to embolization in selected cases 1

4. Combined Approaches

• For patients with both reflux and obstruction:
  • Combined or staged treatment (addressing both components) is superior to ovarian vein embolization alone 1

Follow-up and Monitoring

• Periodic pain assessments using validated tools:

  • Genitourinary pain index (GUPI)
  • Interstitial cystitis symptom index (ICSI)
  • Visual analog scale (VAS) 1

• Regular reassessment of treatment efficacy to discontinue ineffective treatments 1

Important Considerations

• PCS is frequently underdiagnosed, leading to anxiety and depression in affected women 2
• Incompetent and dilated pelvic veins can be found in asymptomatic women, making correlation with clinical symptoms crucial 3
• A multidisciplinary approach involving gynecologists, pain specialists, and interventional radiologists is recommended for complex cases 1
• Patient education about the chronic nature of PCS and available treatment options is essential 1