Pelvic venous congestion By Mr Stefan Ponosh, Vascular & Endovascular Surgeon, Hollywood “If only I had found out earlier” is an all-too-common lament made by patients presenting with often years of “investigated” chronic pelvic pain (CPP) when the diagnosis of Pelvic Congestion Syndrome (PCS) is made. CPP affects between 15-43% of 18-50 females worldwide, comprising 10-20% of all outpatient gynaecologic visits and up to 40% of gynaecologic laparoscopies. CPP has significant physical, emotional and quality of life implications. PCS is estimated to account for 30-40% of CPP. CPP is a challenging, often multifactorial diagnosis with multiple possible differential (mainly gynaecological) diagnoses. Over a third of patients following investigation are left with chronic pain with mild arguably asymptomatic gynaecological pathology or labelled as “chronic pain patients”. PCS in simple terms is the development of ‘varicose veins’ in the pelvis. It can be associated with intermittent, often cyclical but sometimes persistent chronic abdominal and pelvic pain lasting over six months. Common in women of reproductive age (parous more than nulliparous), PCS is also associated with secondary venous complications after menopause.
Key messages PCS is an underdiagnosed, underrecognised, underappreciated, and often ignored common cause of CPP PCS is relatively easily diagnosed and has a low risk and successful treatment Better awareness and clinical suspicion for the specific symptomatology of PCS may speed up PCS diagnosis and treatment.
sensation to pelvis or perineum and genitals, bloating, dyspareunia, lower abdominal pain, stress incontinence and irritable bowellike symptoms. Outside the pelvis there may be varicose veins (vulva, groin, buttock, lower limb), leg swelling or heaviness and chronic venous symptoms (e.g. eczema pigmentation). Symptoms can be variable in nature and position and are often worsened by menstrual periods due to hormonal influences on pelvic venous dilatation and worsened by increased abdominal pressure (e.g. lifting, prolonged standing).
The primary pathophysiology is associated with incompetence of the ovarian (uni or bilateral, left more than right side) and pelvic vein plexus. This does not affect the localisation of patient symptoms. In the vast majority of cases this is associated with ovarian vein incompetence. However, in some cases it can be associated with internal iliac vein incompetence. This incompetence can be congenital (nulliparous women), but pregnancy is strongly associated with secondary incompetence. This incompetence results in pelvic venous hypertension and dilated congested pelvic varicosities involving the uterus, rectum, bladder, vagina, and secondary lower limb pressurisation causing inflammation and the constellation of PCS symptoms. Rarely, pelvic venous hypertension can be associated with extrinsic venous compression caused by a May-Thurner Syndrome (iliac vein compression between iliac artery and spine) or a Nutcracker Syndrome (renal vein compression between aorta and superior mesenteric artery). Specialist pelvic ultrasound utilising transvaginal imaging has been
Pelvic congestion syndrome symptoms inside the pelvis include pelvic pain, ‘heaviness’ or ‘dragging’
Varicose veins
42 | JULY 2022
Ovarian vein embolisation – incompetent ovarian vein (right) and OVE (left)
MEDICAL FORUM | MEN 'S HEALTH
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