Pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear and the optimum treatment is uncertain. It primarily affects multiparous women in the reproductive age group and no cases have occurred in menopausal women.
The most commonly made diagnosis in chronic pelvic pain is endometriosis (31%). The majority are undiagnosed or improperly diagnosed. In the majority of women with no obvious pathological cause for their pain, they may be suffering from pelvic congestion syndrome (PCS) instead. PCS accounts for up to 30% of patients presenting with chronic pelvic pain and is characterized by symptoms of dysmenorrhea, dysuria, and dyspareunia. PCS also carries a psychological burden and is often found in conjunction with increased levels of anxiety, stress, and depression. It can often be found in conjunction with vulvar and pelvic varices in women and with varicoceles in men. Many patients will present with chronic, dull, lower abdominal pain often accompanied by dyspareunia and bladder irritability and urgency. The pain is typically relieved by lying down and exacerbated by standing up or increased intra-abdominal pressure, such as during pregnancy and the premenstrual period. Pain during intercourse or during the postcoital period is not uncommon.
Differential diagnosis in chronic pelvic pain is lengthy and includes pelvic inflammatory disease, endometriosis, pelvic tumors, interstitial cystitis, and inflammatory bowel disease
It has been found that there is gross dilatation, incompetence, and reflux of the ovarian veins in women with PCS. Anatomic and hormonal factors lead to venous insufficiency of the ovarian veins and/or internal iliac veins, resulting in periovarian pelvic varicosities, thus producing pelvic venous congestion. Ovarian vein dilatation, stasis, and/or reflux on pelvic venography are common findings in multiparous premenopausal women but only some have symptoms. The use of venoconstrictors or ovarian vein ligation has produced relief of pain in some patients. Studies using Dihydroergotamine during an acute attack demonstrated relief of pain when the veins in the pelvis constrict. (Lancet. 1987;2(8555):351) Multiparous women (who have had multiple pregnancies) have a higher prevelance of PCS due to the 50% increase in vascular congestion that occurs in pregnancy, leading to venous incompetence and reflux in the non-pregnant state and thus pain.
Extrinsic compression of the left renal vein between the aorta and superior mesenteric artery leads to an increase incidence of PCS on the left side of the pelvis. This results in left flank pain, hematuria, and pelvic congestion. It has been noted that the left ovarian veins have no valves, increasing congestion on the left side as well.
Menopause decreases the incidence of PCS because estrogen acts as a venodilator and of course is no longer present after menopause.
Examination will show tenderness on abdominal examination over the adnexa and history of postcoital aching pain. Ultrasound may show incompetent and dilated ovarian veins which are common but nonspecific findings. Also, dilatation of the left ovarian vein with reversed caudal flow, presence of tortuous and dilated pelvic venous plexuses, and dilated arcuate veins crossing the uterine myometrium are found in PCS with increased diameters of the left ovarian vein at 7.9 mm (usual is 5.4 mm).
Selective ovarian and internal iliac venography through catheterization of the right and left ovarian veins via a percutaneous femoral or jugular approach demonstrate abnormally dilated ovarian veins (>10 mm in diameter), sluggish blood flow, reflux causing retrograde fill and congestion of the ovarian venous plexus in PCS. Up to 80 % of premenopausal women are found to have pelvic varicosities and venous stasis.
Computed tomography (CT) and magnetic resonance (MR) imaging identify tortuous, dilated pelvic and ovarian veins, broad ligament vascular congestion, and ovarian varicoceles better than ultrasound imaging. A growing body of data suggests that magnetic resonance venography (MRV) and CT scan are just as useful as pelvic Ultrasound.
Treatment of PCS consists of hormone therapy, embolotherapy, sclerotherapy, and endovascular and open surgery
First options are medical treatment using Goserelin, Medroxyprogesterone acetate, or etongestrel implants to hormonally treat the vascular congestion.
Invasive therapies that are successful include procedures such as embolization or sclerotherapy of the ovarian veins with or without the internal iliac veins. This involves interventional radiology:
Pelvic congestion link
Success rates of ovarian vein embolization range from 89 to 100 percent. Surgical ligation of the ovarian vein has been associated with improvement in pain in approximately 75 percent.
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