link
Bookmarks
Pelvic Congestion Syndrome
Brandt C. Wible, MD; Gloria M. Salazar, MD
To access 4,300 diagnoses written by the world's leading experts in radiology, please log in or subscribe.Log inSubscribe

KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        TERMINOLOGY

        • Definitions

          • Pelvic congestion syndrome (PCS): Chronic pelvic pain lasting > 6 months due to pelvic venous incompetence (PVI) and associated venous distension
            • Caused by retrograde flow through incompetent valves in dilated ovarian/internal iliac veins
              • Tortuous, congested pelvic/periuterine veins
            • Risk factors may include heredity, hormonal influence, pelvic surgery, retroverted uterus, history of varicose veins, and multiple pregnancies
            • Symptoms and signs
              • Pressure/heaviness in pelvis/vulva/thighs
                • Often associated with movement, posture, and activities that increase abdominal pressure
              • Vulvar/lower extremity superficial varicosities
              • Dyspareunia (71%), dysmenorrhea (66%)
              • Bladder irritability, urinary frequency,
              • Symptoms worse at day's end, relief when supine, exacerbated by menses
            • Hallmark of PCS is its disappearance after menopause
              • Syndrome may result from gonadal dysfunction, combined with venous dilatation/congestion
          • Anatomic considerations in PCS
            • Ovarian veins (OV)
              • Left OV drains into left renal vein
                • May communicate with inferior mesenteric vein
              • Right OV drains directly into IVC
                • Enters IVC below right renal vein
              • Often multiple ovarian venous trunks bilaterally
              • Traditionally thought OV incompetency requires vein diameter > 10 mm
                • Diameter does not seem to correlate with PVI
                • Frequent communications between ovarian/internal iliac varices; thus ovarian venous trunks may not be dilated
              • Higher left-side incidence of PCS
                • Absent OV valves on left (15%); on right (6%)
            • Internal iliac veins (IIV)
              • Have both visceral and parietal branches
                • Visceral branches: Vesical, vaginal, and uterine plexi; rectal, labial, clitoral branches
                • Parietal branches: Iliolumbar, superior/inferior gluteal, obturator veins, sacral venous plexus
            • Utero-ovarian arcade
              • Formed by uterine-OV anastomoses
                • Right/left endometrial veins may communicate
              • Incomplete embolization may result in persistent symptoms via utero-ovarian arcade pelvic varices
          • PVI etiology
            • Multifactorial
              • 1° valvular insufficiency
                • Absent/incompetent valves
              • Venous outflow obstruction
                • "Nutcracker" anatomy compresses left renal vein, elevates venous pressure/may cause reflux
              • Anomalous anatomic variants
                • Retroaortic left renal vein may elevate venous pressure/may cause OV reflux
              • Dysfunctional vasomotor hormonal regulation
                • Uterine/OV hormone sensitive

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Equipment Preparation

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          • Things to Avoid

                            OUTCOMES

                            • Complications

                              • Expected Outcomes

                                Selected References

                                1. Borghi C et al: Pelvic congestion syndrome: the current state of the literature. Arch Gynecol Obstet. 293(2):291-301, 2016
                                2. Koo S et al: Pelvic congestion syndrome and pelvic varicosities. Tech Vasc Interv Radiol. 17(2):90-5, 2014
                                3. Laborda A et al: Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 36(4):1006-14, 2013
                                4. Monedero JL et al: Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology. 27 Suppl 1:65-73, 2012
                                5. Black CM et al: Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol. 21(6):796-803, 2010
                                6. Tu FF et al: Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 65(5):332-40, 2010
                                7. Gandini R et al: Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 31(4):778-84, 2008
                                8. Ratnam LA et al: Pelvic vein embolisation in the management of varicose veins. Cardiovasc Intervent Radiol. 31(6):1159-64, 2008
                                9. Koc Z et al: Association of left renal vein variations and pelvic varices in abdominal MDCT. Eur Radiol. 17(5):1267-74, 2007
                                10. Kwon SH et al: Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 30(4):655-61, 2007
                                11. Liddle AD et al: Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 22(3):100-4, 2007
                                12. Kim HS et al: Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 17(2 Pt 1):289-97, 2006
                                13. Pavkov ML et al: Quantitative evaluation of the utero-ovarian venous pattern in the adult human female cadaver with plastination. World J Surg. 28(2):201-5, 2004
                                14. Venbrux AC et al: Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 13(2 Pt 1):171-8, 2002
                                15. Venbrux AC et al: Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol. 11(4):395-9, 1999
                                16. Beard RW et al: Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 2(8409):946-9, 1984
                                Related Anatomy
                                Loading...
                                Related Differential Diagnoses
                                Loading...
                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Procedure

                                    • Post Procedure

                                      TERMINOLOGY

                                      • Definitions

                                        • Pelvic congestion syndrome (PCS): Chronic pelvic pain lasting > 6 months due to pelvic venous incompetence (PVI) and associated venous distension
                                          • Caused by retrograde flow through incompetent valves in dilated ovarian/internal iliac veins
                                            • Tortuous, congested pelvic/periuterine veins
                                          • Risk factors may include heredity, hormonal influence, pelvic surgery, retroverted uterus, history of varicose veins, and multiple pregnancies
                                          • Symptoms and signs
                                            • Pressure/heaviness in pelvis/vulva/thighs
                                              • Often associated with movement, posture, and activities that increase abdominal pressure
                                            • Vulvar/lower extremity superficial varicosities
                                            • Dyspareunia (71%), dysmenorrhea (66%)
                                            • Bladder irritability, urinary frequency,
                                            • Symptoms worse at day's end, relief when supine, exacerbated by menses
                                          • Hallmark of PCS is its disappearance after menopause
                                            • Syndrome may result from gonadal dysfunction, combined with venous dilatation/congestion
                                        • Anatomic considerations in PCS
                                          • Ovarian veins (OV)
                                            • Left OV drains into left renal vein
                                              • May communicate with inferior mesenteric vein
                                            • Right OV drains directly into IVC
                                              • Enters IVC below right renal vein
                                            • Often multiple ovarian venous trunks bilaterally
                                            • Traditionally thought OV incompetency requires vein diameter > 10 mm
                                              • Diameter does not seem to correlate with PVI
                                              • Frequent communications between ovarian/internal iliac varices; thus ovarian venous trunks may not be dilated
                                            • Higher left-side incidence of PCS
                                              • Absent OV valves on left (15%); on right (6%)
                                          • Internal iliac veins (IIV)
                                            • Have both visceral and parietal branches
                                              • Visceral branches: Vesical, vaginal, and uterine plexi; rectal, labial, clitoral branches
                                              • Parietal branches: Iliolumbar, superior/inferior gluteal, obturator veins, sacral venous plexus
                                          • Utero-ovarian arcade
                                            • Formed by uterine-OV anastomoses
                                              • Right/left endometrial veins may communicate
                                            • Incomplete embolization may result in persistent symptoms via utero-ovarian arcade pelvic varices
                                        • PVI etiology
                                          • Multifactorial
                                            • 1° valvular insufficiency
                                              • Absent/incompetent valves
                                            • Venous outflow obstruction
                                              • "Nutcracker" anatomy compresses left renal vein, elevates venous pressure/may cause reflux
                                            • Anomalous anatomic variants
                                              • Retroaortic left renal vein may elevate venous pressure/may cause OV reflux
                                            • Dysfunctional vasomotor hormonal regulation
                                              • Uterine/OV hormone sensitive

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Equipment Preparation

                                                  • Procedure Steps

                                                    • Alternative Procedures/Therapies

                                                      POST PROCEDURE

                                                      • Things to Do

                                                        • Things to Avoid

                                                          OUTCOMES

                                                          • Complications

                                                            • Expected Outcomes

                                                              Selected References

                                                              1. Borghi C et al: Pelvic congestion syndrome: the current state of the literature. Arch Gynecol Obstet. 293(2):291-301, 2016
                                                              2. Koo S et al: Pelvic congestion syndrome and pelvic varicosities. Tech Vasc Interv Radiol. 17(2):90-5, 2014
                                                              3. Laborda A et al: Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 36(4):1006-14, 2013
                                                              4. Monedero JL et al: Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology. 27 Suppl 1:65-73, 2012
                                                              5. Black CM et al: Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol. 21(6):796-803, 2010
                                                              6. Tu FF et al: Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 65(5):332-40, 2010
                                                              7. Gandini R et al: Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 31(4):778-84, 2008
                                                              8. Ratnam LA et al: Pelvic vein embolisation in the management of varicose veins. Cardiovasc Intervent Radiol. 31(6):1159-64, 2008
                                                              9. Koc Z et al: Association of left renal vein variations and pelvic varices in abdominal MDCT. Eur Radiol. 17(5):1267-74, 2007
                                                              10. Kwon SH et al: Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 30(4):655-61, 2007
                                                              11. Liddle AD et al: Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 22(3):100-4, 2007
                                                              12. Kim HS et al: Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 17(2 Pt 1):289-97, 2006
                                                              13. Pavkov ML et al: Quantitative evaluation of the utero-ovarian venous pattern in the adult human female cadaver with plastination. World J Surg. 28(2):201-5, 2004
                                                              14. Venbrux AC et al: Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 13(2 Pt 1):171-8, 2002
                                                              15. Venbrux AC et al: Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol. 11(4):395-9, 1999
                                                              16. Beard RW et al: Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 2(8409):946-9, 1984