Pelvic congestion syndrome
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View Gagandeep Singh's current disclosuresAt the time the article was last revised Daniel J Bell had no financial relationships to ineligible companies to disclose.
View Daniel J Bell's current disclosures- Pelvic venous incompetence
- Pelvic congestion syndrome (PCS)
- Pelvic venous congestion
- Pelvic venous insufficiency
- Pelvic venous incompetence (PVI)
- Female varicocele
- Ovarian varicocele
Pelvic congestion syndrome (some prefer pelvic venous insufficiency 9) is a condition that results from retrograde flow through incompetent valves in ovarian veins. It is a commonly missed and potentially treatable cause of chronic abdominopelvic pain.
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Epidemiology
It tends to be more common in multiparous, premenopausal women who typically present with chronic pelvic pain for more than 6 months 1. The overall population prevalence may approach ~30% in patients where the presenting complaint is chronic pelvic pain 12.
Clinical presentation
Patients often have non-cyclical chronic (typically dull and aching) pelvic pain. In certain cases there may be thigh or vulvar varices. It is often considered a diagnosis of exclusion.
Pathology
Pelvic congestion syndrome is considered the female homologue to testicular varicocele. It may be caused by:
venous obstruction: such as retroaortic left renal vein
compression of left renal vein by SMA also known as nutcracker phenomenon
incompetent valves in ovarian vein
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Radiographic features
The diagnosis of pelvic congestion syndrome is established by the demonstration of multiple dilated, tortuous parauterine veins with a width >4 mm or an ovarian vein diameter greater than 5-6 mm 4.
Ultrasound
ovarian vein >5-6 mm (positive predictive value of 71-83%)
may show multiple dilated veins in the adnexa with reversed venous flow on colour Doppler, especially after Valsalva manoeuvre
the venous calibres may increase on real time during Valsalva
prominent myometrial veins may also be present 1-8
CT
Contrast enhanced CT typically shows dilated pelvic and ovarian veins. The supine position during scanning may underestimate the size of venous dilatation.
MRI
MR venography
May show dilated veins. Time of flight (TOF) imaging can be performed where contrast is not required.
Signal characteristics
T1: seen as flow voids which represent engorged arcuate vessels
T2: mostly high signal but can vary dependent on velocities from low signal to iso signal
GE: high signal
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Treatment and prognosis
Treatment options include coil embolisation of the gonadal vein: ovarian vein embolisation. Surgical (e.g. laparoscopic) ligation of the ovarian vein may also be an option in selected cases. The presence of multiple collaterals between iliac and ovarian venous plexuses may cause recurrence of symptoms.
History and etymology
Pelvic congestion syndrome was first described in 1857 by Louis Alfred Richet (1816-1891), a French anatomist and surgeon 10.
See also
References
- 1. Park SJ, Lim JW, Ko YT et-al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol. 2004;182 (3): 683-8. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Umeoka S, Koyama T, Togashi K et-al. Vascular dilatation in the pelvis: identification with CT and MR imaging. Radiographics. 24 (1): 193-208. doi:10.1148/rg.241035061 - Pubmed citation
- 3. Venbrux AC, Chang AH, Kim HS 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. 2002;13 (2 Pt 1): 171-8. - Pubmed citation
- 4. Haaga JR, Boll D. CT and MRI of the whole body. Mosby. (2009) ISBN:0323053750. Read it at Google Books - Find it at Amazon
- 5. Ignacio EA, Dua R, Sarin S et-al. Pelvic congestion syndrome: diagnosis and treatment. Semin Intervent Radiol. 2008;25 (04): 361-8. doi:10.1055/s-0028-1102998 - Free text at pubmed - Pubmed citation
- 6. Liddle AD, Davies AH. Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 2008;22 (3): 100-4. Pubmed citation
- 7. Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent Radiol. 2013;30 (04): 372-80. doi:10.1055/s-0033-1359731 - Free text at pubmed - Pubmed citation
- 8. Sharma K, Bora MK, Varghese J et-al. Role of trans vaginal ultrasound and Doppler in diagnosis of pelvic congestion syndrome. J Clin Diagn Res. 2014;8 (7): OD05-7. doi:10.7860/JCDR/2014/8106.4570 - Free text at pubmed - Pubmed citation
- 9. Knuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W. Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. (2015) AJR. American journal of roentgenology. 204 (2): 448-58. doi:10.2214/AJR.14.12709 - Pubmed
- 10. Djembi YR, Viard B, Trouilloud P, Trost O, Salomon C. [Alfred-Louis-Dominique Richet (1816-1891): education, anatomy and surgery]. (2015) Morphologie : bulletin de l'Association des anatomistes. 99 (324): 14-7. doi:10.1016/j.morpho.2014.11.002 - Pubmed
- 10. Smith PC. The outcome of treatment for pelvic congestion syndrome. (2012) Phlebology. 27 Suppl 1: 74-7. doi:10.1258/phleb.2011.012s01 - Pubmed
- 11. Asciutto G, Asciutto KC, Mumme A, Geier B. Pelvic venous incompetence: reflux patterns and treatment results. (2009) European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 38 (3): 381-6. doi:10.1016/j.ejvs.2009.05.023 - Pubmed
- 12. Omer Saadat Cheema & Paramvir Singh. Pelvic Congestion Syndrome. StatPearls Publishing. 2021. PMID 32809625
Incoming Links
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