Pelvic Congestion Syndrome and it's management
Welcome to our dedicated webpage on Pelvic Congestion Syndrome (PCS), a complex and often misunderstood condition affecting a significant number of women. PCS is characterized by chronic pelvic pain, arising from a myriad of causes including varicose veins in the pelvic region, hormonal imbalances, and anatomical variations. This page aims to provide comprehensive insights into the nuances of PCS, encompassing its clinical manifestations, risk factors, and the intricate pelvic venous drainage system. We delve into the various diagnostic imaging techniques, from ultrasound to venography, which play a crucial role in identifying and understanding the condition. Our focus also extends to the latest treatment options, particularly ovarian vein embolization, and its outcomes. Whether you’re a healthcare professional, a patient seeking information, or just curious about this condition, our webpage offers a thorough and accessible exploration of Pelvic Congestion Syndrome.
Understanding anatomy related to PCS:
| Aspect | Subcategory | Specific Details |
|---|---|---|
| Main Collecting Veins | - | 1. Internal Iliac Veins (IIVs), 2. Ovarian Veins (OVs), 3. Superior Rectal Veins |
| Internal Iliac Vein Drainage (drains four groups of afferent tributaries) | 1. Anterior Visceral Veins | Uterine, vaginal, vesical, and rectal veins |
| 2. Parietal Veins - drainage variability into anterior branch of IIV is 50% as a single vein, 36% as a double vein, 14% as a plexiform | Inferior gluteal, obturator, and pudendal veins | |
| 3. Posterior Pelvic Parietal Veins | Ileolumbar and sacral veins | |
| 4. Extrapelvic Veins | Superior gluteal vein | |
| IIV Joining | - | Joins the external iliac vein (EIV) to form the common iliac vein (CIV), which combines with the contralateral side to form the IVC |
| Ovarian Vein Drainage | Left Ovarian Vein | Drains into the left renal vein (99%) or the IVC directly (1%) |
| Right Ovarian Vein | Drains into the IVC directly (98%) or into the right renal vein (2%) | |
| Intra/Extra-Pelvic Anastomoses (Needs careful assessment prior to embolisation of pelvic veins) | With lower limb venous drainage | 1. Gluteal-ischiatic venous plexus 2. Internal pudendal venous plexus |
| Anastomoses Details | Gluteal Vein | Drains through sacral plexus, anastomoses with collateral from the great saphenous vein (external circumflex iliac vein) |
| Ischiatic Vein | Drains posterior thigh, drains into internal pudendal vein, anastomoses with femoral vein and great saphenous vein | |
| Internal Pudendal Vein | Anastomoses indirectly with great saphenous vein through clitoral veins or directly with external pudendal vein in labia majora. | |
| Valve Presence and Competency | - | 1. 13%-15% of women lack valves in the left OV; 2. 6% women lack valves in the right OV. 3. When valve are present 43% of the left and 35%-41% of the right valves are incompetent |
| Anatomical Variations | Internal Iliac Vein Draining | Into contralateral common iliac vein |
| Duplicated Inferior Vena Cava | Duplicated IVC with azygous and hemiazygous communication | |
| Reverse-Angle Renal Veins | Alternative left ovarian vein drainage into segmental veins of the kidney | |
| Direct Connection | Anterior left internal iliac vein to the inferior vena cava |
Comprehensive Overview: Pelvic Congestion Syndrome (PCS)
| Aspect | Sub-Aspect | Description |
|---|---|---|
| Clinical Symptoms | Nature of Pain | 1. Chronic (3–6-month duration), dull, and aching pain in lower abdomen or pelvis, not related to menstrual cycle (non-cyclic). 2. Persistent for several months. |
| Aggravating Factors | 1. Worsened by standing for long periods, sexual activity, menstrual periods, and during pregnancy. | |
| Additional Symptoms | The Uterus | - Menstrual Changes: Changes in frequency, duration, or amount of flow; excessive flow not often a major issue. - Menstrual Pain: Increased discomfort common; premenstrual onset. - Intermenstrual Bleeding: Often reported, usually slight, not related to ovulation. - Uterine Examination Findings: Enlargement more common in multiparous women; retroversion and fibroids noted in some cases. |
| The Cervix | - Leucorrhea: Frequently reported, mucopurulent or clear mucus. - Physical Findings: Endocervicitis, erosion, hypertrophy, history of previous cauterisation. |
|
| The Ovaries | - Unilateral Abdominal Pain: Common, often right-sided. - Physical Examination Findings: Tenderness and enlargement of ovaries. |
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| The Peritoneum | - Appearance in Extreme Cases: Small pools of ascitic fluid, soft edematous subperitoneal tissues, fine adhesions. - Acute Abdominal Pain Attacks: Simulating peritonitis; emotional reaction often disproportionate to pain. |
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| The Vulva | - Symptoms: Pain, burning, swelling sensations, pruritus. - Physical Appearance: Violaceous color, labial edema, sometimes varicosities. - Hypertrophy of Labia Minora: Noted especially in nulliparous women. |
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| The Bladder and Urethra | - Urinary Discomfort: Reported in a significant number of patients. - Cystoscopic Findings: Congestion and edema of the trigone. |
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| Rectum | - Symptoms: Pronounced rectal symptoms rare; hemorrhoids not significantly frequent. - Literature Observations: Rectal pain, painful defecation, hemorrhoidal vein dilatation as part of the syndrome. |
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| The Breasts | - Association with Pelvic Symptoms: Breast pain and swelling often associated with onset or increase of pelvic symptoms. - Physical Characteristics: Sensitivity and nodularity in breasts noted in several cases. |
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| Examination Findings | 1. Presence of varicose veins in areas like vulva, perineum, buttocks, and legs. 2. Sensitivity in the ovarian area and pain following sexual intercourse. |
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| Predisposing Factors | Environmental Influences | 1. Factors include having been pregnant, surgeries in the pelvic area, use of estrogen-based treatments, obesity, history of vein inflammation, and occupations requiring long periods of standing or lifting. |
| Anatomical Factors | 1. Unique variances in the structure of pelvic veins, especially those involving ovarian vein drainage. 2. Renal “Nutcracker” syndrome, portal hypertension, iliac compression syndrome (May–Thurner syndrome), and inferior vena cava (IVC) syndrome. |
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| Genetic Predisposition (Young women with no pre-disposing factor) | 1. Indications of hereditary patterns. 2. Links to genetic mutations in certain genes such as FOXC2, TIE2, NOTCH3. |
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| Mechanisms Underlying PCS | Valve Dysfunction in Veins | 1. Dysfunction in venous valves leading to backflow and expansion of veins. |
| Structural Changes in Vein Walls | 1. Damage and inflammation of vein walls and muscles. 2. Results in prolonged expansion and backflow of veins. |
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| Role of Estrogen | 1. Estrogen leading to weakening and expansion of veins and their valves. 2. Facilitates the onset of venous incompetence. |
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| Pain Origins in PCS | Activation of Pain Sensors | 1. Expansion and stagnation in swollen veins might trigger specific pain receptors. 2. Medications targeting nerve pain are often effective. |
| Release of Pain-Inducing Neurotransmitters | 1. Heightened levels of pain-related neurotransmitters like substance P and calcitonin gene-related peptide (CGRP) in swollen pelvic veins. 2. Blocking these neurotransmitters can reduce pain. |
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| Imaging Modalities | Pelvic Ultrasound (transvaginal with Doppler. ) | 1. Identifies veins > 6 mm in diameter, assesses blood flow dynamics. 2. Impeded or flow reversal in ovarian veins, arcuate veins 3. Variable duplex waveform on Valsalva's manoeuver 4. Associated Polycystic ovary |
| CT and MRI (presence of at least four ipsilateral pelvic veins varying in caliber, with at least one measuring > 4 mm in maximum diameter or an ovarian vein diameter of > 8 mm) | 1. Shows dilated, tortuous tubular structures in pelvic area. 2. Benefit of additional information of pelvic anatomy and pathology. 3. On MRI, varicosities are bright on T2-weighted sequences. |
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| Venography (Considered the gold standard) | 1. Looks for ovarian vein diameter > 10 mm, 2. Venous incompetence, 3. Venous congestion in pelvic, thigh and valvovaginal areas with retrograde filling. 4. Contrast reflux in left renal vein. |
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| Dilatation and Reflux | Identifying Candidates for Embolization | 1. Utilizes imaging to determine vein dilation and reflux extent. 2. Considers symptoms and vein diameters (normal: <4 mm, asymptomatic reflux: 4-8 mm, symptomatic: >8 mm). |
| Clinical Management | Medical Management (suppressing ovarian function) | 1. Initial approach often includes hormonal treatments to reduce symptoms. Resistance develops on long term use. 2. Combined oral hormonal contraceptives, nonsteroidal anti-inflammatory drugs, Medroxyprogesterone acetate (50 mg per day) or gonadotropin-releasing hormone analogs used. |
| Embolization Therapy (increasingly considered as primary treatment for PCS) | 1. Recommended after medical management failure. 2. Involves transcatheter embolization of ovarian veins using various embolic agents like sclerosants, etc. |
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| Surgical Options | 1. Considered in refractory cases or when other pelvic pathologies coexist. 2. Includes laparoscopic ovarian vein ligation or hysterectomy. |
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| Outcomes of Embolization Therapy | Short-Term Efficacy | 1. High technical success rate (around 99%). 2. Immediate symptom relief in many cases. |
| Long-Term Efficacy | 1. Sustained symptom improvement in a significant percentage of patients. 2. Studies report varying degrees of long-term relief. |
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| Recurrence and Complications | 1. Recurrence of symptoms reported in a small fraction (up to 8%). 2. Complications rare but can include coil migration, vessel perforation. |
Transcatheter Embolization in Pelvic congestion syndrome:
| Transarterial Embolization | |
|---|---|
| Anesthesia | Local anesthesia and intravenous sedation |
| Vascular access | 1. Right Common femoral vein 2. Internal Jugular vein 3. Basilic vein |
| Anatomy | 1. Right ovarian vein - is typically located at an acute angle on the right anterolateral inferior vena cava just below the right renal vein. 2. Left ovarian vein - typically drainage into Left renal vein |
| Venography | 1. Looks for ovarian vein diameter > 10 mm, 2. Venous incompetence, 3. Venous congestion in pelvic, thigh and valvovaginal areas with retrograde filling. 4. Contrast reflux in left renal vein. 5. Internal pudendal and obturator veins and their relevant collaterals are super-selected, because of their intra/extra-pelvic anastomoses with the lower limb venous drainage and vulval veins. |
| Embolic Agent (delivery at ovarian vein plexus) | 1. Solid embolic - gelfoam and vascular plugs 2. Liquid embolic - Sclerosant sodium tetradecyl sulfate (STS) and adhesive polymers like NBCA (glue) 3. Avoid Coils - high risk of migration and embolization of internal iliac vein. These complications can be limited with the use of detachable coils. |
| Endpoint | 1. Use of intra-operative TVS doppler to look for blood flow in pelvic veins or 2. Occlusion of the target vein and subsequent non-opacification of the distal vessel |
| Technical success | 99% of patients |
| Recurrent varicocele following surgical therapy | < 8% of patients |
| Complications | 1. Peri-procedural pain - 5-7 days 2. Fever 3. Venous injury and hematoma formation 4. Coil migration |
- Bartl, T., Wolf, F. & Dadak, C. Pelvic congestion syndrome (PCS) as a pathology of postmenopausal women: a case report with literature review. BMC Women’s Health 21, 181 (2021). https://doi.org/10.1186/s12905-021-01323-3
- Diwakar, Previn. Pelvic Congestion Syndrome: A Review of the Treatment of Symptomatic Venous Insufficiency in the Ovarian and Internal Iliac Veins by Catheter-Directed Embolization. Indian Journal of Vascular and Endovascular Surgery 5(4):p 244-252, Oct–Dec 2018. | DOI: 10.4103/ijves.ijves_83_18
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