What is the best management approach for Pelvic Congestion Syndrome (PCS)?

Management of Pelvic Congestion Syndrome

First-Line Treatment

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

Ovarian vein embolization demonstrates:

• Technical success rates of 96-100% 1, 2
• Long-term symptomatic relief in 70-90% of cases 1, 2
• Low complication rates with transient pain being the most common side effect (occurs in <2% of cases) 1

Diagnostic Criteria and Approach

Pelvic congestion syndrome (PCS) is characterized by:

• Chronic pelvic pain lasting more than six months 2
• Pain that worsens during menses or after prolonged standing 3
• Associated symptoms including dyspareunia, urinary urgency, or constipation 3, 2

Diagnostic imaging is essential:

• Non-invasive imaging (ultrasound, CT, MRI) helps exclude other causes of chronic pelvic pain 2
• Trans-catheter venography remains the gold standard for definitive diagnosis 2
• IVUS evaluation is recommended for cases involving nonthrombotic iliac vein lesions 4

Treatment Algorithm

1. Endovascular Interventions (First-Line)

• Ovarian vein embolization: Most effective first-line treatment with 75% symptomatic improvement 4, 1

  • Can be performed with sclerosants (sodium tetradecyl sulfate, polidocanol) 4, 1
  • Technical success rates of 96-100% with long-term relief in 70-90% of cases 2

• Internal iliac vein embolization: Safe and effective adjunct treatment 4, 1

  • Often performed in addition to ovarian vein embolization 4
  • Particularly useful when both reflux and obstruction are present 4

• Left renal vein stenting: For cases involving nutcracker syndrome 4

  • Increasingly preferred over open surgical approaches due to lower morbidity 4, 1
  • Demonstrates remission of pelvic venous symptoms 4, 1

2. Surgical Options (Second-Line)

• Laparoscopic ovarian vein ligation: Complete resolution of symptoms reported in all 23 patients in one study 4, 1
  • Consider when endovascular approaches fail or are contraindicated 4

3. Conservative Management (Adjunctive)

• Pelvic floor rehabilitation therapy: Including myofascial manipulation and modified Kegel exercises 1

  • Avoid standard Kegel exercises which can worsen symptoms 1

• Pharmacological management:

  • Amitriptyline for chronic pain management 1
  • NSAIDs for symptomatic relief 5
  • Venoprotective agents as adjunctive therapy 5

• Lifestyle modifications:

  • Avoiding tight-fitting clothing 1
  • Managing constipation which may worsen symptoms 1
  • Stress management practices 1

Special Considerations

Combined Pathology

For patients with both gonadal vein reflux and nonthrombotic iliac vein lesions:

• Combined or staged iliac vein stent placement and ovarian vein embolization shows improved symptom relief compared to ovarian vein embolization alone 4
• Fixed lesions on IVUS (>50% area reduction or >61% diameter stenosis) are more likely to be pathological and benefit from intervention 4

Complications and Follow-up

• Transient colic-like pain is common after foam sclerotherapy but typically resolves within minutes 1
• For patients with persistent symptoms after initial embolization, a second procedure may be considered 1
• Long-term follow-up is important as some studies report symptom recurrence requiring additional intervention 6

Evidence Quality and Limitations

• Most evidence comes from retrospective studies and case series 7
• The longest duration of follow-up currently reported is five years 7
• Lack of prospective, multicenter randomized controlled trials remains a significant barrier to complete acceptance of both the diagnosis and management approaches 2
• Treatment efficacy is best documented for ovarian vein embolization, with limited high-quality data for other approaches 4, 7