Management of Suspected Pelvic Congestion Syndrome with Prominent Left Adnexal Vessels on Ultrasound
The next step is to perform a comprehensive duplex Doppler ultrasound of the pelvis to confirm the diagnosis by demonstrating three key sonographic criteria: dilated tortuous pelvic veins >4 mm, slow or reversed blood flow (<3 cm/s), and dilated arcuate veins in the myometrium communicating with pelvic varicosities. 1
Initial Diagnostic Confirmation
When ultrasound identifies prominent left adnexal vessels suggestive of pelvic congestion syndrome (PCS), the critical first step is to distinguish true pelvic varicosities from other adnexal pathology, as the gray-scale appearance of dilated veins can mimic cystic adnexal masses 1.
Essential Doppler Ultrasound Criteria
The diagnostic ultrasound evaluation must include 1:
- Measurement of pelvic vein diameter: A left ovarian vein diameter ≥5 mm has a 71% positive predictive value for PCS, increasing to 83% at ≥6 mm
- Flow assessment: Documentation of slow (<3 cm/s) or reversed blood flow within the dilated vessels
- Myometrial evaluation: Identification of dilated arcuate veins communicating with pelvic varicosities
Important technical consideration: The examination should be performed in both supine and semi-standing positions with Valsalva maneuver, as this significantly increases diagnostic sensitivity 1. This is a common pitfall—performing the study only in the supine position may miss the diagnosis.
Advanced Imaging for Definitive Diagnosis
If the ultrasound findings remain equivocal or if the vessels cannot be adequately traced to their pelvic origin, MRI/MR venography is the next appropriate imaging modality 2. This is particularly important because:
- Ultrasound has inherent limitations related to body habitus, bowel gas, and operator dependence 1
- Vulvar or posterior thigh varicose veins of pelvic origin are rarely traceable to their source on ultrasound alone 1
- MRI provides superior anatomic detail of the entire pelvic venous system 2
When to Proceed to Venography
Diagnostic venography should be reserved as an immediate precursor to therapeutic intervention (ovarian vein embolization), not as a standalone diagnostic test 3. Venography remains the gold standard for definitive diagnosis but is invasive and should only be performed when:
- Non-invasive imaging (ultrasound and/or MRI) has confirmed PCS
- The patient has failed conservative/medical management
- Therapeutic embolization is planned during the same procedure 3
Clinical Correlation Requirements
Before proceeding with any intervention, confirm the patient has the characteristic clinical presentation 4, 3:
- Chronic pelvic pain lasting >6 months
- Pain worse during menses or after prolonged standing
- Associated symptoms: dyspareunia (common), urinary urgency, or constipation
- Pain typically worse in pre-menstrual period and exacerbated by walking, standing, and fatigue 3
Treatment Pathway
Once PCS is confirmed by imaging and clinical correlation:
Ovarian vein embolization (OVE) is the definitive treatment, with technical success rates of 96-100% and long-term symptomatic relief in 70-90% of cases 3. The transbrachial approach is recommended as first-choice for bilateral PCS 4.
Critical Prognostic Factor
Patients with residual pelvic varicosities measuring >5 mm on post-treatment ultrasound are more likely to have persistent symptoms 4. This underscores the importance of complete embolization and appropriate follow-up imaging at 6-12 months.
Key Pitfalls to Avoid
- Do not mistake dilated pelvic veins for complex adnexal masses: Always use color/power Doppler to confirm vascular nature 1
- Do not perform venography as initial diagnostic test: Use non-invasive imaging first 2, 3
- Do not skip the semi-standing/Valsalva portion of the ultrasound: This significantly impacts diagnostic accuracy 1
- Do not proceed to treatment without excluding other causes of chronic pelvic pain: Endometriosis, adhesions, chronic PID, and other gynecologic pathology must be ruled out 5