What are the treatment options for pelvic congestion syndrome?

Treatment Options for Pelvic Congestion Syndrome

Ovarian vein embolization (OVE) is the first-line interventional treatment for pelvic congestion syndrome (PCS) with technical success rates of 96-100% and symptomatic relief in 70-90% of cases. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Initial Imaging:

   • Transvaginal and transabdominal ultrasound with Doppler (first-line)
   • Diagnostic criteria: engorged periuterine/periovarian veins >8mm, low-velocity flow patterns, altered flow with Valsalva maneuver, and retrograde flow in ovarian veins 1

2. Advanced Imaging (when ultrasound is inconclusive):

   • MRI/MR angiography
   • CT with IV contrast (for suspected venous anatomic variants)
   • Venography (reserved for cases where intervention is planned) 1

Treatment Algorithm

First-Line: Conservative Management

• Venoactive agents and ergot alkaloid derivatives
• Compression garments
• Lifestyle modifications:
  • Avoiding prolonged standing
  • Regular exercise
  • Weight management
  • Heat/cold application over painful areas
  • Pelvic floor muscle relaxation techniques 1

Second-Line: Pharmacological Options

• Amitriptyline
• Cimetidine
• Analgesics for pain management 1

Third-Line: Interventional Procedures

1. Ovarian Vein Embolization (OVE):

   • Gold standard interventional treatment
   • Performed via percutaneous transcatheter approach
   • Can be done on an outpatient basis under local anesthesia
   • Sclerosing agents such as 3% sodium tetradecyl sulfate are commonly used 1, 2

2. Additional Interventions (as needed):

   • Internal iliac vein embolization
   • Left renal vein stenting for cases related to nutcracker syndrome
   • Treatment for nonthrombotic iliac vein lesions (NIVL) associated with PCS 1

Fourth-Line: Surgical Options

• Historically included hysterectomy and ovarian vein ligation
• Now largely superseded by less invasive endovascular treatments 2, 3

Monitoring and Follow-up

• Clinical assessment at one month post-treatment
• Gynecological and ultrasound examinations at 6-12 months to monitor:
  • Reduction in periovarian varicosities
  • Persistence of symptoms 1, 2

Special Considerations

Transbrachial Approach

• Proposed as first-choice treatment for bilateral PCS
• Less expensive than surgery
• Safe, effective, and minimally invasive 2

Multidisciplinary Management

• Complex cases benefit from collaboration between:
  • Gynecologists
  • Pain specialists
  • Interventional radiologists 1

Psychological Support

• Cognitive behavioral therapy
• Biofeedback therapy
• Stress management practices (meditation, imagery)
• Important for managing pain perception and coping strategies 1

Common Pitfalls and Caveats

1. Delayed Diagnosis: PCS is often underdiagnosed with an average time to diagnosis of up to four years after initial presentation 4

2. Incomplete Treatment: Symptoms may persist in women with pelvic varicosities measuring over 5mm at follow-up ultrasound 2

3. Misdiagnosis: Important to rule out other causes of chronic pelvic pain:

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

4. Limited High-Quality Evidence: Despite promising results from endovascular treatments, there is a lack of high-level evidence and randomized controlled trials 5

5. Overlooking Bilateral Disease: PCS can occur bilaterally (most common), or unilaterally on either the right or left side 2