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Pelvic Congestion Syndrome

What is Pelvic Congestion Syndrome (PCS)?

A cause of chronic pelvic pain, not related only to menstrual cycle and present for greater than six months.

In 75% of women, no definite cause for symptoms is found

This syndrome was first described in 1857

It is associated with dilation of the pelvic veins, specifically the ovarian veins and sometimes the internal iliac veins.

Ligation (blockage) of the veins has been shown to reduce pain.

What causes PCS?

Incompetence of the valves and dilatation of the ovarian veins and other veins draining the pelvis.
  • Some women (6-15%) naturally have no valves or have incompetent valves.
  • During pregnancy, ovarian blood flow increases up to 60 times, resulting in valve damage.
  • Incompetence allows backwards flow of blood causing varicose veins in the pelvis.
  • The varices put pressure on the structures of the pelvis leading to the symptoms.
Who gets PCS?
  • Usually women between ages 20 and 40
  • More common in women with multiple pregnancies.
  • 90% of women with unexplained chronic pelvic pain have dilated pelvic veins and venous congestion.
What are the symptoms?
  • Chronic abdominal or pelvic pain, sometimes back pain.
  • Usually worse after prolonged standing, after sexual intercourse, during menstruation and with fatigue, exercising. Symptoms are relieved by laying down.
  • May be associated with varicose veins in the thigh, buttocks or vaginal area.
  • Other symptoms include bladder irritation or urgency, pelvic or abdominal fullness or pressure.
How is it diagnosed?
  • A thorough investigation, including laparoscopy must be done to rule out other diseases.
  • It is suspected when no other cause for chronic pelvic pain can be identified.
  • Most routine urologic and gynecologic investigations are normal in this syndrome.
  • It may be diagnosed by CT scan or MRI. Ultrasound may not be as sensitive in detection as CT or MRI.
  • Venography is used for confirmation, and is done at the time of embolization to prove varices and outline anatomy before treatment.
How is it treated?
  • Surgical treatment
  • Laparoscopic or open surgical removal or clipping of the ovarian veins
    • Hysterectomy
    • Uterine suspension
  • Medical treatment (uncommon)
    • Progesterone (to decrease ovarian function)
    • Ergotamine (to contract the veins)
    • Ovarian vein embolization
What is Ovarian Vein Embolization?
  • A non-surgical technique preferably done after menses and before ovulation.
  • Minimally invasive
  • Performed by interventional radiologists
  • Local instead of general anaesthetic
  • Outpatient procedure
  • Short recovery time (most patients are back to normal within 1 week. Pain is variable 24-48 hours after the procedure, subsiding over 2-3 days.
How is it done?
  • A small nick is made in the skin over the jugular vein in the neck or femoral vein in the groin.
  • A catheter is advanced into the vein and into the renal vein into the ovarian vein.
  • X-ray dye is used to show the anatomy of that vein
  • The vein is then blocked using either metal coils or a special glue both of which are deployed through the catheter
What will I experience?
  • The doctor will clean and numb the skin.
  • You may feel some pressure (but not pain) as the doctor advances the catheter.
  • You will likely feel a warmth whenever the doctor injects the x-ray dye to take a picture of your vessels.
  • During the procedure you will receive medication to control pain and make you sleepy.
  • The procedure lasts less than 1 hour.
Summary
  • A very effective technique
    • 58-78% of women experience relief of symptoms.
  • It may take months before you notice improvement in symptoms.
  • No adverse effects on later pregnancies.





About Interventional Radiology

Interventional radiologists are board-certified physicians who specialize in minimally invasive, targeted treatments that have less risk, less pain and less recovery time compared to open surgery. They use their expertise in interpreting X-rays, ultrasound, MRI and other diagnostic imaging studies to understand, visualize and diagnose the full scope of the disease's pathology and to map out the procedure tailored to the individual patient. Then during the procedure, they image as they go to guide tiny instruments, such as catheters, through blood vessels or skin, to treat diseases at the site of the illness nonsurgically.

Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists complete preliminary training in Diagnostic Radiology and advanced training in Vascular and Interventional Radiology. The American Board of Radiology certifies their specialized training.