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Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 99-101

What's about pelvic congestion syndrome

Director of Vascular Centre, Nuova Villa Claudia, Via Flaminia Nuova 280, Rome, Italy; President of the International Union of Angiolog

Date of Submission20-Jul-2020
Date of Decision10-Aug-2020
Date of Acceptance12-Aug-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Prof. Pier Luigi Antignani
Via Germanico 211, 00192, Rome

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/VIT.VIT_25_20

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How to cite this article:
Antignani PL. What's about pelvic congestion syndrome. Vasc Invest Ther 2020;3:99-101

How to cite this URL:
Antignani PL. What's about pelvic congestion syndrome. Vasc Invest Ther [serial online] 2020 [cited 2021 Jul 27];3:99-101. Available from: https://www.vitonline.org/text.asp?2020/3/4/99/304839

The Pelvic Congestion Syndrome (PCS) is an often overlooked and untreated condition with chronic symptoms, which may include pelvic pain, perineal heaviness, urgency of micturition, and postcoital pain, caused by ovarian and/or pelvic vein reflux and/or obstruction, and which may be associated with vulvar, perineal, and/or lower extremity varices.[1]

Ovarian vein dilatation is seen in 10% of women, up to 60% of whom may develop PCS. Nearly 30% of the patients with CPP as the sole cause of their pain and an additional 15% have PCS along with another pelvic pathology. However, ovarian vein diameter does not correlate well with ovarian vein insufficiency.[2]

The etiology of PCS is multifactorial which includes mechanical (congenital or acquired), hormonal, and psychosomatic risk factors.

Venous hypertension is a leading factor in the development of PCS, which is a result of abnormal venous flow, particularly with centrifugal/retrograde direction which develops pelvic varices due to reflux in the ovarian or internal iliac vein, or centripetal/antegrade pathological flow, which is induced by deficiency of pelvic vein outflow, which is conditioned by intraluminal (thrombotic) or extraluminal (compressive) causes.

The structural changes of pelvic varicosities in similar of varicose veins such as fibrosis of the tunica intima and media and muscular hypertrophy. Women with PCS tend to have a larger uterus and more cystic changes in ovaries than healthy women, but cystic changes in the ovaries range from a classic polycystic appearance to the presence of clusters of four to six cysts of 5–15 mm in diameter in bilaterally enlarged ovaries.[3]

Noncyclical pelvic pain, which can be exacerbated by postural changes, walking, sexual intercourse, and also during menstruation and dyspareunia, is the main clinical symptom of PCS.

The main clinical sign is the presence of varicose veins on perineal, vulval, gluteal, or posterior thigh areas.[3],[4]

Transabdominal ultrasound which in most cases is the first step on instrumental diagnosis, can exclude intrinsic pelvic conditions, demonstrate pelvic varicosities, and suggest ovarian vein insufficiency. Transabdominal ultrasound has a great diagnostic value because of direct visualization of the left ovarian vein. An ovarian vein diameter of 6 mm on transabdominal ultrasonography has been reported to have a 96% positive predictive value for pelvic varices; although diameter measurements alone do not correlate well with ovarian vein reflux and so the examination should also look for reflux with the patient in a 45° position.[5],[6],[7],[8],[9]

Transvaginal ultrasound is considered to be the examination of choice because it offers better visualization of the pelvic venous plexus compared to transabdominal ultrasound. The presence of circular or linear venous structures with a diameter >5 mm is indicative of pelvic varicosities. Reversed caudal blood flow may be seen in the ovarian veins and dilated arcuate veins may be seen crossing the myometrium.[9],[10],[11]

Duplex-ultrasonography of the veins of lower extremities is the necessary part of the imaging protocol for improved evaluation of PCS, especially in the presence of atypical (perineal, vulval, gluteal, or posterior thigh) varicose veins.[9],[11]

Cross-sectional computed tomography has poor diagnostic relevance because it doesn't give information about hemodynamic changes in pelvic veins. On computed tomography, the varicosities are isodense to other abdominal veins on postcontrast imaging. This method has the capability to exclude other pelvic pathologies.[7],[9]

On magnetic resonance venography, pelvic varicosities are identified as enlarged tortuous tubular structures in the trajectory of the ovarian veins, around the adnexa, and in the pelvic floor. Furthermore, the renal veins can be assessed for signs of compression (Nutcracker syndrome), as well as the common and/or external iliac vein.[7],[8],[9]

Catheter-directed retrograde selective venography of ovarian and internal iliac veins is a method of choice for the diagnosis of pelvic venous pathology.[4],[5],[6]

Usage of intravascular ultrasound for the diagnosis of PCS is very rare and mostly performed for detecting compressive syndromes (Nutcracker and May–Thurner syndrome) or in postthrombotic damage of the veins.

The sensitivity of laparoscopy for the diagnosis of PCS is approximately 40%. Diagnostic findings during laparoscopy include existence of prominent enlarged broad ligament veins and may reveal pelvic varices.[2],[5],[8]

For the confirmation of diagnosis of PCS, other pathologies of the pelvis must be excluded, such as fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, ovarian, and Fallopian tube diseases, pelvic tumors, cystitis, inflammatory bowel diseases and adhesions, pelvic arterial venous malformations, and portal hypertension.

Symptomatic (pain relief) therapy includes analgesics, nonsteroidal anti-inflammatory drugs, and psychotropic drugs, but the effect of such therapy is transient.

Hormonal therapy (medroxyprogesterone acetate and gonadotropin-releasing hormone) shows a good therapeutic effect, but long-term use is not recommended because of the high risk of osteoporosis.

Early enhancement of venous tone with Micronized Purified Flavonoid Fraction (MPFF) may restore pelvic circulation for patients with PCS; MPFF significantly reduces the symptoms, such as pain and heaviness, and improves patients' QOL.[9]

Current surgical treatment includes open or laparoscopic surgery to ligate the insufficient veins. However, these procedures are rarely performed as they are more invasive than endovascular embolization procedures, and require a general anesthetic and a longer recovery period.[10]

Injecting foam sclerosant (sodium tetradecyl sulfate or aetoxisclerol) can be used for occlusion of truncal (gonadal) veins and also, for the treatment of atypical varicose veins of perineal, vulval, gluteal, or posterior thigh localization.[6],[8],[9]

Transcatheter embolization therapy is the method of choice for the treatment of PCS. The aim of embolization is to occlude insufficient venous axes as close as possible to the origin of the leak. In pelvic venous disorders, these will be the gonadal axes, pelvic varicose veins, and insufficient tributary branches of the internal iliac veins.[2],[9],[10]

Venous compressive syndromes could also lead to pelvic venous plexus hypertension and result in PCS. In these cases, placing a stent can treat the compression: May–Thurner's syndrome – nonthrombotic compression of the left common iliac vein by the right common iliac artery, “Nutcracker” or “Mesoaortic” syndrome – compression of the left renal vein between the SMA and aorta or the aorta and the lumbar spine in the case of a retroaortic let renal vein. Care must be taken not to overdiagnose nutcracker syndrome as the “pseudo-nut-cracker” appearance can show renal vein narrowing due to blood being stolen away by an incompetent ovarian vein.[3],[5]

Catheter-directed selective embolization allows to treat not only the reflux from the ovarian and internal iliac vein, but also the pathological leak from pelvic veins to the veins of lower extremities. After the endovascular treatment, the pelvic pain significantly has reduced. Despite that for the last 20 years a lot of data about the effectiveness of ovarian and/or internal iliac vein embolization for treatment of PCS has published, it is very difficult to compare clinical results due to the lack of the common protocol. Practically each center used own criterion for evaluation the effectiveness of different diagnostic and treatment options.[5],[6],[9]

Treatment of choice for PCS is pelvic vein embolization. Complications after this kind of treatment are very rare but may be developing during the procedure, in the early or late postprocedural period. The importance of each incident must be evaluated by the type and severity of the complication.[9]

  References Top

Lazarashvili Z, Antignani PL, Monedero JL. Pelvic congestion syndrome: prevalence and quality of life. Phlebolymphology 2016;23:123-6.  Back to cited text no. 1
Monedero JL, Ezpeleta SZ, Perrin M. Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology 2012;27 Suppl 1:65-73.  Back to cited text no. 2
Antignani PL, Geroulakos G, Bokuchava M. Clinical aspects of pelvic congestion syndrome. Phlebolymphology 2016;23:127-9.  Back to cited text no. 3
Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Ovarian vein diameter cannot be used as an indicator of ovarian venous reflux. Eur J Vasc Endovasc Surg 2015;49:90-4.  Back to cited text no. 4
Greiner M, Dadon M, Lemasle P, Cluzel P. How does the patho-physiology influence the treatment of pelvic congestion syndrome and is the result long-lasting? Phlebology 2012;27 Suppl 1:58-64.  Back to cited text no. 5
Lazarashvili Z, Antignani PL, Monedero JL, Ezpeleta SZ. Pelvic congestion syndrome: How to correctly manage it today. Acta Phlebologica 2016;17:23-6.  Back to cited text no. 6
Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 2018;97:776-86.  Back to cited text no. 7
Gianesini S, Antignani PL, Tessari L. Pelvic congestion syndrome: How to correctly manage it today. Phlebolymphology 2016;23:142-5.  Back to cited text no. 8
Antignani PL, Lazarashvili Z, Monedero JL, Ezpeleta SZ, Whiteley MS, Khilnani NM, et al. Diagnosis and treatment of pelvic congestion syndrome: UIP consensus document. Int Angiol 2019;38:265-83.  Back to cited text no. 9
Mahmoud O, Vikatmaa P, Aho P, Halmesmäki K, Albäck A, Rahkola-Soisalo P, et al. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord 2016;4:355-70.  Back to cited text no. 10
Whiteley MS, Dos Santos SJ, Harrison CC, Holdstock JM, Lopez AJ. Transvaginal duplex ultrasonography appears to be the gold standard investigation for the haemodynamic evaluation of pelvic venous reflux in the ovarian and internal iliac veins in women. Phlebology 2015;30:706-13.  Back to cited text no. 11


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