What is Pelvic Congestion Syndrome?

Pelvic Congestion Syndrome (PCS)

Pelvic Congestion Syndrome is a condition characterized by chronic pelvic pain caused by dilated and incompetent pelvic veins, primarily affecting premenopausal women, with diagnosis confirmed by imaging findings of engorged periuterine and periovarian veins >8mm with retrograde flow. 1

Definition and Clinical Presentation

Pelvic Congestion Syndrome is characterized by:

• Chronic pelvic pain lasting more than six months
• Pain that worsens with prolonged standing, during menstruation, after physical exertion, and during/after sexual intercourse
• Associated symptoms may include:
  • Dyspareunia (painful intercourse)
  • Urinary urgency
  • Constipation
  • Post-coital ache
  • Dysmenorrhea
  • Bladder irritability
  • Rectal discomfort 1, 2

The condition predominantly affects multiparous women of reproductive age and can significantly impact quality of life, potentially leading to anxiety and depression if left undiagnosed and untreated 2.

Pathophysiology

The exact etiology remains uncertain but is likely multifactorial:

• Valvular insufficiency in pelvic veins
• Venous obstruction
• Hormonal factors (particularly estrogen overstimulation)
• Anatomic variants
• Multiple pregnancies may contribute to development 1, 3

It's important to note that incompetent and dilated pelvic veins can be found in asymptomatic women, making the causal relationship between venous congestion and pain sometimes difficult to establish 3.

Diagnostic Criteria

According to the American College of Radiology, definitive diagnosis requires:

• Engorged periuterine and periovarian veins >8mm
• Low-velocity flow patterns
• Altered flow with Valsalva maneuver
• Retrograde flow in ovarian veins 1

Diagnostic Imaging

The recommended diagnostic approach follows a stepwise progression:

1. Initial Imaging: Transvaginal and transabdominal ultrasound with Doppler

   • Assesses engorged periuterine and periovarian veins
   • Evaluates flow patterns and retrograde flow
   • Provides anatomic overview of pelvic structures 1

2. Secondary Imaging (if ultrasound is inconclusive):

   • MRI/MR angiography - comparable to conventional venography
   • CT with IV contrast - useful for venous anatomic variants but limited in providing dynamic flow information 1

3. Definitive Imaging:

   • Venography - gold standard for diagnosis
   • Reserved for cases where intervention is planned
   • Allows for immediate intervention 1, 2

Differential Diagnosis

It's crucial to rule out other causes of chronic pelvic pain:

• Pelvic inflammatory disease
• Endometriosis
• Adhesive disease
• Hydrosalpinx or pyosalpinx
• Interstitial cystitis/bladder pain syndrome
• Musculoskeletal disorders 1

Treatment Options

Treatment follows a stepwise approach:

1. Conservative Management (First-Line)

• Venoactive agents
• Ergot alkaloid derivatives
• Compression garments
• Pharmacological options (amitriptyline, cimetidine) 1

2. Lifestyle Modifications

• Avoiding prolonged standing
• Regular exercise
• Weight management
• Heat or cold application over painful areas
• Pelvic floor muscle relaxation techniques
• Stress management practices (meditation, imagery)
• Dietary modifications 1

3. Interventional Treatment

• Ovarian vein embolization (OVE) - first-line interventional treatment

  • Technical success rates: 96-100%
  • Symptomatic relief in 70-90% of cases
  • Low complication rates
  • Can be performed on an outpatient basis 1, 2

• Other interventional options:

  • Internal iliac vein embolization
  • Left renal vein stenting (for nutcracker syndrome)
  • Treatment for nonthrombotic iliac vein lesions (NIVL) 1

Follow-up and Monitoring

• Clinical assessment at one month post-treatment
• Gynecological and ultrasound examinations at 6-12 months
• Monitor for reduction in periovarian varicosities and persistent symptoms 1, 4

Prognosis

• Untreated PCS can lead to chronic debilitating pain
• After OVE, symptoms may persist in women with pelvic varicosities measuring over 5mm on follow-up ultrasound 4
• Poor prognostic factors include persistent dyspareunia, which may indicate coexisting causes of pelvic pain 5

Common Pitfalls

• Underdiagnosis - PCS is frequently overlooked or misdiagnosed due to nonspecific symptoms
• Misattribution - Not all pelvic pain with venous varices is PCS; the causal relationship must be established
• Fragmented care - Patients often see multiple specialists before diagnosis
• Delayed treatment - Can lead to psychological distress and reduced quality of life 2

A multidisciplinary approach involving gynecologists, pain specialists, and interventional radiologists is essential for optimal management of complex cases 1, 2.