Reviewer:
Editor: Akshaar Brahmbhatt MD
Contributor: Akshaar Brahmbhatt, MD; Zachary Nuffer, MD
Pelvic venous disorders encompass a broad spectrum of venous anomalies that can cause pelvic pain, hematuria, pelvic, and lower extremity varicose veins, among other symptoms. Pelvic Congestion Syndrome falls under the umbrella of pelvic venous disorders. 1) In Pelvic Congestion Syndrome, incompetent ovarian veins cause reflux into and dilation of the pelvic venous system. PCS results from reflux mainly through thought the ovarian veins. This is usually due to acquired venous incompetence (e.g. increased venous capacity during pregnancy, venous dilation due to estrogen, etc.) or congenital absence of the venous valves. However, other causes of venous incompetence should be considered include Nut-Cracker syndrome, May-Thurner Syndrome, arteriovenous malformations, cirrhosis, central venous thrombosis, etc. These should be considered during patient work-up and during the procedure itself.2) 3) The pelvic venous system communicates with the veins of the pelvic organs including the uterus, ovaries, bladder, colon as well as major pelvic veins, including the iliac veins, inferior vena cava and left renal vein. These vessels also communicate through the pelvic floor and via perforating veins with the superficial and lower extremity vasculature. Due to the interconnected nature of these veins, patients can present with a variety of symptoms, including superficial pelvic varicosities, lower extremity varicose veins, urinary urgency, dysmenorrhea and dyspareunia. Although the mechanism of chronic pain is not fully understood, it is thought to result from the activation of perivascular nociceptors. 4) 5) After careful patient selection, patients may undergo catheter-based venographic evaluation of the ovarian veins through the left renal and directly from the IVC for evidence of venous incompetence, including reflux and dilation. Embolization of the incompetent ovarian veins can lead to symptomatic relief. Multiple studies have demonstrated durable symptomatic relief in patients with dysmenorrhea, dyspareunia, and urinary urgency.6)
Patient selection is critical when evaluating patients for pelvic congestion syndrome. It is important to consider the wide variety of other conditions that can cause pelvic pain.7)
Gastrointestinal | Irritable Bowel Syndrome, Inflammatory bowel disease, Diverticulosis, etc. |
Gynecological | Endendometriosis, Pelvic inflammatory disease, Fibroids, Ovarian cysts, etc. |
Musculoskeletal | Myofascial Pain, Fibromyalgia, Ligamentous Strain, etc. |
Neurological | Neuralgia, Radiculopathy, etc. |
Psychiatric | Depression, Somatization, Abuse, etc. |
Urological | Cystitis, Renal Stones, etc. |
Physical exam to evaluate for pelvic and lower extremity varicosities should be performed. Physical exam and patient positioning limitations may inform choice of access site, groin vs neck. Lastly, imaging can be used as an adjuvant to the history and physical exam. Trans-abdominal and Trans-vaginal ultrasound can be performed to look for dilated pelvic veins, those greater than 6mm. Advanced cross-sectional imaging such as CT and MRI can also be used for look for the presence of dilated ovarian and pelvic venous vessels while also helping to exclude other confounding pathologies.8)
Patients should be counseled on outcomes in that the vast majority of women have positive results with some improvement, but a complete resolution does not occur in the majority of cases. Additionally, a small fraction of patients experience no difference in pain symptoms. There are no known studies evaluating outcomes related to pregnancy, but several trials have reported successful pregnancy after this treatment.9) 10)
Female patient presenting with chronic pelvic pain in the absence of other likely etiology. Factors that suggest PCS warranting catheter venography. History of multiple pregnancies, life-style factors including prolonged standing. Presence of gluteal, vulvar and/or perineal varicosities. Lower extremity varicosities originating from the upper inner thigh.
Absolute:
Relative:
Article | Study | Outcome | Results |
---|---|---|---|
Kim et al[6] (JVIR) | N=131 Retrospectively treated consecutive patients followed prospectively | Visual Analog Scale for pain at 3 months, 6 months and annually (mean follow up 45 months) | Mean pelvic pain significantly improved in the majority of patients 83% improved, 13% remained unchanged and 4% reported worsening symptoms. |
Chung and Huh[8] (Journal of Experimental Medicine) | N=106 (52 treated with embolization) RCT (three groups, embolotherapy, hysterectomy + bilateral oophorectomy + hormone replacement therapy, hysterectomy with unilateral oophorectomy) | Visual analog scale for pain at 3, 6, and 12 months after the procedure | Statistically significant decrease in VAS scores with emblotherapy and hysterectomy. However more significant decrease with Embolotherapy. |
Laborda et al. [9] (CVIR) | N = 202 | Visual Analog Scale with follow up at 1, 3, 6 months and annually for 5 years. | Clinical success in 93.85% of patients with decrease in VAS scores. Complete resolution of symptoms in 33.52% of patients. |
Sandwich Technique |
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Use a 6 F Fogarty balloon catheter and 0.035“ coils. Deploy the coils through the catheter and then inflate the balloon and inject the sclerotherapy solution (e.g. 2 mL 3%Sodium_tetradecyl_sulfate + 1 mL lipiodol foamed with 6 mL air.) Wait 5 minutes and then deploy then next set of coils. Retract and repeat. |
Multiple studies have reported transient pain following embolization or a “post-embolization syndrome” which included lumbar pain, transient fever. Patients can also develop phlebitis at the access site. These can be treated symptomatically with non-steroid anti-inflammatory medication and usually self-resolve. 20) 21)
The majority of complications do not result in significant morbidity or mortality. The most common finding after treatment is transient pain after embolization. This is more common with the use of sclerosants. 22)
Complication | Frequency |
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Transient pain following embolization | 8-100% |
Coil Migration or embolic | <2% |
Vein Perforation | <1% |
Patients should be followed clinically. It is recommended that patients are followed up in clinic several weeks and again several months after the procedure to access for symptom recurrence and possible venous recanalization. 23)