What are the treatment options for pelvic congestion syndrome?

Treatment Options for Pelvic Congestion Syndrome

Ovarian vein embolization is the most effective first-line treatment for pelvic congestion syndrome, with early substantial pain relief observed in 75% of women, which generally increases and sustains over time. 1

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential:

• Pelvic congestion syndrome (PCS) is characterized by chronic pelvic pain lasting more than six months with no evidence of inflammatory disease 2
• Common symptoms include pain exacerbated by walking, standing, and fatigue; post-coital ache, dysmenorrhea, dyspareunia, bladder irritability, and rectal discomfort 2
• Non-invasive imaging (ultrasound, CT, MRI) is essential for diagnosis and exclusion of other conditions causing chronic pelvic pain 2
• Trans-catheter venography remains the gold standard for definitive diagnosis and is typically performed immediately before treatment 2

Treatment Algorithm

First-Line Treatment: Endovascular Interventions

• Ovarian vein embolization (OVE):

  • Technical success rates of 96-100% with long-term symptomatic relief in 70-90% of cases 2
  • Typically performed using coils, sclerosing agents, or a combination 1
  • Sclerosants (sodium tetradecyl sulfate, polidocanol) show significant symptomatic improvement of approximately 75% 1
  • Low complication rates with transient pain being the most common side effect (occurs in <2% of cases) 1

• Internal iliac vein embolization:

  • Often performed in addition to ovarian vein embolization 1
  • Safe and effective in treating pelvic venous insufficiency and reducing pelvic pain 1

Second-Line Treatments: Surgical Interventions

• Laparoscopic ovarian vein ligation:

  • One study reported complete resolution of symptoms in all 23 patients treated 1
  • Less commonly used since the development of less invasive endovascular techniques 2

• Left renal vein stenting:

  • For cases related to nutcracker syndrome 1
  • Limited studies have demonstrated remission of pelvic venous symptoms 1
  • Increasingly preferred over open surgical approaches due to lower morbidity 1

Third-Line Treatments: Conservative Management

• Pelvic floor rehabilitation therapy:

  • Includes myofascial manipulation, uterine conditioning, and modified Kegel exercises 3
  • May be beneficial for patients with associated pelvic floor dysfunction 3
  • Should not include standard Kegel exercises, which can worsen symptoms in some patients 1

• Manual physical therapy techniques:

  • Appropriate for patients with pelvic floor tenderness 1
  • Techniques include maneuvers that resolve pelvic, abdominal and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars 1
  • Standard pelvic floor strengthening exercises should be avoided 1

• Pharmacological management:

  • Analgesics for pain control 4
  • Hormonal treatments may be considered 4
  • Amitriptyline may be beneficial for chronic pain management 1

Special Considerations

Approach to Treatment Selection

• Consider a multidisciplinary approach involving gynecologists, interventional radiologists, pain specialists, and physical therapists 2
• For bilateral pelvic congestion syndrome, the transbrachial approach is recommended as first-choice treatment 4
• For patients with persistent symptoms after initial embolization, a second procedure may be considered, though evidence on efficacy is contradictory 1

Common Pitfalls and Caveats

• Under-diagnosis of PCS can lead to anxiety and depression 2
• Symptoms may persist in women with pelvic varicosities measuring over 5 mm on ultrasound after treatment 4
• Transient colic-like pain is common after foam sclerotherapy but typically resolves within 5 minutes 1
• Limited high-quality research exists, particularly involving practicing obstetricians and gynecologists 5
• Consider the impact of constipation, which may worsen symptoms in some patients 1

Long-term Management

• Regular follow-up is recommended to assess treatment efficacy 4
• Behavioral modifications may help manage symptoms, including avoiding tight-fitting clothing and managing constipation 1
• Stress management practices should be encouraged to improve coping techniques and manage stress-induced symptom exacerbations 1