Pelvic Congestion

Syndrome
Durham JD, Machan L
Semin Intervent Radiol.
2013;30:372380
Presentan: Daniel N. Aji
Desember 2014

Epidemiology
Chronic pelvic pain in women 18-50 yo: 15%
(USA)
60% women with chronic pelvic pain the
cause remains undiscovered
Chronic pelvic pain pelvic congestion
syndrome (PCS)
PCS: 31% in symptomatic population
Belenkey et al (2002): ovarian varices
prevalence 9.9% (27/273); mostly reported
chronic pelvic pain

Definition
Chronic pelvic pain: noncyclic pelvic
pain of more than 6 months duration
Pelvic congestion syndrome: chronic
pelvic pain secondary to PVI and
associated pelvic venous distension
Pelvic venous insufficiency:
retrograde flow through incompetent
gonadal and pelvic veins
Black CM, Thorpe K, Venrbux A, et al. Research reporting standards for endovascular
treatment of pelvic venous insufficiency. J Vasc Interv Radiol 2010;21:796 803

Anatomy
Lower uterus & Vagina
uterine vein internal iliac
vein
Left ovarian plexus left
ovarian vein left renal
vein
Right ovarian plexus
inferior vena cava

Patophysiology
PCS: ovarian vein reflux and/or pelvic
varicosities (Ovarian vein diameter >5 mm)
Primary: congenital / aqcuired ovarian vein
absence/incompetence (nonobstructive)
Secondary: nutcracker syndrome, May-Thurner
syndrome

Women > men, multiparous women

Ovarian varicosities are seen more
frequently after pregnancy
Many pelvic veins are devoid of valves and
have weak attachments between the
adventitia and supporting connective tissue

Venkatachalam S, Bumpus K, Kapadia SR, Gray B, Lyden S, Shishehbor MH. The nutcracker
syndrome. Ann Vasc Surg 2011;25(8): 11541164

Diagnosis
PCS: clinical syndrome + anatomic findings
chronic pelvic pain of greater than 6 months
duration secondary to PVI and associated pelvic
venous distention
Symptoms:
Noncyclical, positional lower back, pelvic, and upper
thigh pain
Pain is exacerbated before or during menses and
may be associated with dyspareunia and prolonged
postcoital discomfort
most severe at the end of the day, exacerbated by
standing or heavy activity, and are diminished with
supine positioning.

Diagnosis (2)
Pelvic examination: cervical motion and
ovarian point tenderness.
Postcoital ache + ovarian point tenderness
94% sensitive and 77% specific for PVI
Patients undergoing evaluation for PCS and
PVI fall into:
incidentally found pelvic varices
unusual vulvar or upper thigh varices that
complicate lower extremity insufficiency with or
without pelvic pain
painful pelvic varicosities secondary to PVI

Jung SC, Lee W, Chung JW, et al. Unusual causes of varicose veins in the lower
extremities: CT venographic and Doppler US findings. Radiographics 2009;29(2):525
536

Jung SC, Lee W, Chung JW, et al. Unusual causes of varicose veins in the lower
extremities: CT venographic and Doppler US findings. Radiographics 2009;29(2):525
536

Imaging Evaluation
Exclude common causes of intrinsic pelvic
pathology (endometriosis, PID,
postoperative adhesions, adenomyosis or
leiomyoma)
Transabdominal + transvaginal US
pelvic varices and ovarian venous reflux
Sonographic findings: enlarged ovarian
veins greater than 6 mm in diameter with
reversed bloodflow; pelvic varicocele (>5
mm); dilated (>5 mm) arcuate veins
crossing the uterine myometrium
between pelvic varicoceles

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
688

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):683688

Imaging Evaluation (2)

Venography is indicated when a suspicion
for PCS exists (although US normal)
Confirm the diagnosis & therapy
Venography findings:
Renal vein reflux into dilated ovarian veins
(>5mm),
stagnation of contrast in the pelvic veins,
contralateral reflux across the midline, and
demonstration of vulvoperineal or thigh
varices

Treatment
Coil embolization of the ovarian vein,
unilaterally or bilaterally, has been the
most common approach to eradicate
ovarian vein reflux
Partial or significant relief of symptoms in
70 to 100% patients
Improvement in 82% with coil embolization
alone (Kwon 2007)
Improvement of VAS in 94% patients
(Laborda 2013)

Kwon SH, Oh JH, Ko KR, Park HC, Huh JY. Transcatheter ovarian vein embolization using coils
for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol
2007;30(4):655661

Treatment (2)
Direct sclerosing of abnormal
pelvic vein was introduced by
Venbrux (2002) using 5% sodium
morrhuate mixed with gelfoam
Significant & partial response in 96%
subject
Decrease of pain level

Gandini R, Chiocchi M, Konda D, et al.

Transcatheter foam sclerotherapy of
symptomatic female varicocele with
sodium-tetradecyl-sulfate foam.
Cardiovasc Intervent Radiol 2008;
31(4): 77884

Gandini R, Chiocchi M, Konda D, et al.

Transcatheter foam sclerotherapy of
symptomatic female varicocele with
sodium-tetradecyl-sulfate foam.
Cardiovasc Intervent Radiol 2008;
31(4): 77884

Treatment (3)
Combination of multiple sclerosant
& ovarian vein mechanical
occlusion
Gandini (2008): 3% sodium tetradecyl
sulfate (STS) foam
Foam was injected until venous stasis
Volume of sclerosant required typically
ranges from 2.5 to 12.5 cc per ovarian
vein

Treatment (4)
Treatmant of PVI secondary to
nutcracker or May-Thurner syndrome
limited data/ experience
Surgical approach better than
endovascular?
Self expanding stent?

Treatment (5)
Ovarian suppression with
medroxyprogesterone or goserelin, or
Surgical ovarian suppression with
bilateral salpingo-oophorectomy
Surgical VS endovascular :
embolization more effective at
reducing pelvic pain

Complication

Major complication: rare

Venous access site complication
Coil migration
Mild to moderate postembolization
pelvic and flank pain

Preprocedure Care
Not related to menstrual or pain
cycle
Patient should be restricted to clear
fluids after midnight for a morning
appointment, and clear fluids after
breakfast for an afternoon
appointment.
Admission to day care

Postprocedure Care and Follow Up

Patient is observed for several hours to permit
hemostasis at the puncture site
Avoid heavy lifting or exertion more intense than
walking for 3 to 7 days postdischarge
First menstrual period after embolization is often
unusually heavy
Reevaluation at 3 months (transvaginal US)
Unimproved pain at 6 month indication to
repeat venography (recanalized ovarian vein,
undiagnosed outflow obstruction, continued
filling or pelvic varicosities)

CASE 1

 43 yo G3P3 with pelvic pain for 7 years,

worsened since last pregnancy (4 years)
Large left-sided vulvar varices, hemorrhoid
Dull generalized ache, worse with exercise,
at the end of the day, and excruciating for
2 to 3 days before period, severe cramping
after intercourse
Her mother and grandmother had similar
symptoms

Approach
Before venography, patient was
sedated (5 mg of versed and 200 g
of fentanyl)
A sheath was introduced into the right
internal jugular vein
Multipurpose catheter was directed
into the left renal vein and a
diagnostic renal venogram performed
during Valsalva maneuver

3 months later
Pain improved
Dyspareunia had not resolved
Transvaginal US: residual paraovarian
veins, with normal Valsalva

CASE 2

 31 yo, premenopausal, nulliparous

with pelvic pain (left inguinal area)
worsened over 2 years
Pain worse with menses and ovulation
Hemorrhoids and urinary frequency,
postcoital pain
There isnt lower extremity or
vulvoperineal varicosities

 Nutcracker syndrome (CT demonstrated renal

vein compression and an enlarged left gonadal
vein)

 1 month later: pelvic pain resolved,

left flank pain persisted
This case demonstrates the need to
relieve downstream obstruction when
PVI is found to be secondary to
another underlying cause

CASE 3

 45 yo, G4P2 with vulvar varices,

recurrent lower extremities varices, no
pelvic pain
Clinical exam: extensive varicose veins
in the greater saphenous distribution
bilaterally, and left vulvar varicosities
Transvaginal US: dilated paraovarian
veins with abnormal Valsalva flow
accentuation, worse on the left

 Venography: Marked left ovarian vein reflux

Left ovarian vein was embolized using STS and
coils

 3 months later: vulvar and varicose veins were

unchanged.
Patient underwent direct puncture and
sclerotherapy
2.5 cc of 0.5% STS foam was injected on the left
and 1.5 cc on the right

CONCLUSION

 PCS is diagnosed clinically + Imaging

The Society of Vascular Surgery has
recommendaed the endovascular
treatment of PCS
Endovascular therapy: eliminate
ovarian reflux
Upstream obstruction needs to be
ameliorated

THANK YOU