What is the recommended vascular workup for chronic pelvic pain syndrome?

Vascular Workup for Chronic Pelvic Pain Syndrome

For patients with chronic pelvic pain syndrome, the recommended vascular workup should begin with ultrasound with Doppler imaging as first-line diagnostic method, followed by MRI/MR angiography for inconclusive cases or when planning interventions. 1

Initial Vascular Assessment

Ultrasound Evaluation (First-Line)

• Transvaginal ultrasound with Doppler: Essential first component 2, 1

  • Look for engorged periuterine and periovarian veins (>8mm diameter)
  • Assess for low-velocity flow patterns
  • Evaluate flow changes during Valsalva maneuver
  • Document retrograde (caudal) flow of ovarian veins
  • Assess direct connection between engorged pelvic veins and myometrial arcuate veins

• Transabdominal ultrasound with Doppler: Should be performed complementary to transvaginal ultrasound 2, 3

  • Provides anatomic overview of pelvic structures
  • Evaluates uterine artery blood flow (low-resistance waveforms may be present in chronic pelvic pain)

Advanced Imaging (Second-Line)

• MRI/MR Angiography: Problem-solving examination when ultrasound findings are nondiagnostic or inconclusive 2, 1

  • Diagnostic performance comparable to conventional venography 2
  • Use gadolinium-based IV contrast agent for optimal results
  • T2-weighted imaging demonstrates pelvic varices (signal intensity varies with flow velocity)
  • Time-resolved postcontrast T1-weighted imaging shows vein conspicuity and flow direction
  • Can directly demonstrate ovarian vein reflux
  • Provides additional anatomic detail for surgical planning

• CT with IV contrast: Consider when venous anatomic variants are suspected 2, 1

  • May demonstrate:
    • Engorged periuterine and periovarian veins
    • Left renal vein compression (nutcracker syndrome)
    • Asymmetric left-sided pelvic varicosities
  • Limitation: Cannot provide dynamic flow information like US or MRI

Diagnostic Criteria for Pelvic Venous Disorders

Key Findings to Document

1. Dilated pelvic veins (>8mm) 1
2. Retrograde flow in ovarian veins 2, 1
3. Altered flow with Valsalva maneuver 1
4. Presence of pelvic varices 4
5. Evidence of venous obstruction (e.g., nutcracker syndrome, May-Thurner configuration) 5

Potential Pitfalls

• Pelvic venous engorgement and gonadal vein reflux can be present in asymptomatic patients 5
• Multiple investigators have identified estrogen overstimulation in pelvic venous disorders 2
• Morphologic findings of polycystic ovarian syndrome may be present (enlarged ovaries with exaggerated central stroma and multiple small peripherally located follicles) 2

Special Considerations

Venous Compression Syndromes

• Nutcracker Syndrome: Left renal vein compression between superior mesenteric artery and aorta 6

  • Look for left renal vein compression with asymmetric left-sided pelvic varicosities
  • May require stenting of left renal vein if identified 1, 6

• May-Thurner Configuration: Iliac vein compression 5

  • Look for compression with reflux into ipsilateral internal iliac vein
  • Must be treated before addressing gonadal vein incompetence 5

Classification System

• Use the SVP tool to classify patients based on:
  • Clinical symptoms
  • Varicose veins
  • Pathophysiology 7

Recommended Imaging Algorithm

1. Start with ultrasound evaluation:

   • Combined transvaginal and transabdominal approach with Doppler
   • Document vein diameter, flow patterns, and response to Valsalva

2. If ultrasound is inconclusive or intervention is planned:

   • Proceed to MRI/MR angiography with gadolinium contrast
   • Focus on time-resolved postcontrast T1-weighted imaging to demonstrate ovarian vein reflux

3. Consider CT with contrast when:

   • Venous anatomic variants are suspected
   • Evaluating for venous compression syndromes
   • MRI is contraindicated

4. Venography: Reserved for cases where intervention is planned 4

   • Considered gold standard but more invasive
   • Provides definitive diagnosis and opportunity for immediate intervention

Conclusion

The vascular workup for chronic pelvic pain syndrome should follow a systematic approach, starting with non-invasive ultrasound evaluation and progressing to more advanced imaging modalities when necessary. This approach allows for accurate identification of patients with pelvic venous disorders who may benefit from intervention, while minimizing unnecessary invasive procedures.