What are the management options for pelvic congestion syndrome?

Management of 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

Diagnosis and Clinical Presentation

• Pelvic congestion syndrome is characterized by chronic pelvic pain lasting more than six months with no evidence of inflammatory disease, often worse during pre-menstrual periods and exacerbated by walking, standing, and fatigue 2
• Common symptoms include 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 Management

• Ovarian vein embolization has technical success rates of 96-100% with long-term symptomatic relief in 70-90% of cases 1
• Embolization is less expensive than surgery, minimally invasive, and capable of restoring patients to normal function 3
• Common embolization materials include:
  • Sclerosants (sodium tetradecyl sulfate, polidocanol) showing significant symptomatic improvement of approximately 75% 1
  • Stainless-steel coils, which have demonstrated dramatic decrease in pelvic pain 4
• Internal iliac vein embolization may be performed in addition to ovarian vein embolization for comprehensive treatment 1
• Transbrachial approach is recommended as first-choice for bilateral pelvic congestion syndrome 3

Second-Line Treatments

• Laparoscopic ovarian vein ligation has been reported to result in complete resolution of symptoms in all treated patients 1
• Left renal vein stenting is increasingly preferred over open surgical approaches due to lower morbidity for cases related to nutcracker syndrome 1
• For persistent symptoms after initial embolization, a second procedure may be considered 1

Conservative Management

• Multimodal pain management approaches including pharmacological, stress management, and manual therapy should be initiated for symptom control 5
• Amitriptyline may be beneficial for chronic pain management 1
• Behavioral modifications that may help manage symptoms include:
  • Avoiding tight-fitting clothing 1
  • Managing constipation, which may worsen symptoms 1
  • Stress management practices to improve coping techniques 1

Physical Therapy

• Pelvic floor rehabilitation therapy, including myofascial manipulation and uterine conditioning, may be beneficial 1
• Standard Kegel exercises should be avoided as they can worsen symptoms in some patients 1
• Manual physical therapy techniques that resolve pelvic, abdominal and/or hip muscular trigger points may be appropriate for patients with pelvic floor tenderness 1

Potential Complications and Considerations

• Transient colic-like pain is common after foam sclerotherapy but typically resolves within 5 minutes 1
• Coil migration is a potential complication of embolization procedures 6
• The longest reported follow-up for embolization treatment is five years 6
• A multidisciplinary approach involving gynecologists, interventional radiologists, pain specialists, and physical therapists is vital for optimal management 2

Patient Education

• Patients should be educated about what is known and not known about their condition, the benefits versus risks of available treatment alternatives, and that acceptable symptom control may require trials of multiple therapeutic options 5
• Self-care practices and behavioral modifications should be discussed and implemented as feasible 5
• Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations 5