Conditions we treat
Pelvic congestion syndrome (PCS) is a cause of chronic pelvic pain associated with abnormal dilated veins within the pelvis. These pelvic varicose veins can develop when blood flows backwards or pools within the pelvic veins rather than returning normally towards the heart.
Pelvic venous disease may involve the ovarian veins and other veins within the pelvis and can sometimes be associated with varicose veins around the vulva, buttocks or upper thighs. Symptoms and imaging findings vary considerably between patients, so assessment is important before deciding whether treatment is appropriate.
What are the symptoms of pelvic congestion syndrome?
Pelvic congestion syndrome can cause chronic or recurrent pelvic pain, although symptoms vary between patients. The pain is often described as a dull ache or heaviness in the pelvis and may become worse as the day progresses or after prolonged standing.
Other symptoms can include pain during or after sexual intercourse, worsening pelvic pain around menstruation, and discomfort following physical activity. Some patients may also have visible varicose veins around the vulva, buttocks or upper thighs.
Pelvic pain has many possible causes, and the presence of dilated pelvic veins on imaging does not necessarily mean they are responsible for a patient’s symptoms. Assessment therefore involves considering the pattern of symptoms together with appropriate imaging before pelvic congestion syndrome is diagnosed.
WHAT CAUSES PELVIC CONGESTION SYNDROME?
Pelvic congestion syndrome is associated with abnormal dilation and reflux within the pelvic veins. In some patients this is related to failure of the veins to return blood effectively from the pelvis, while in others an underlying venous compression may contribute to the development of pelvic varices.
Pregnancy is an important association, as increased blood flow and enlargement of the pelvic veins during pregnancy can contribute to persistent venous dilation and reflux.
In some patients, pelvic venous disease may also be associated with compression of major abdominal or pelvic veins, such as left renal vein compression (Nutcracker syndrome) or left iliac vein compression (May-Thurner syndrome). Identifying the pattern of venous disease is important because this can influence treatment.
Diagnosis
Pelvic congestion syndrome is diagnosed by considering a patient’s symptoms together with imaging findings. Dilated pelvic veins are relatively common and do not necessarily cause symptoms, so imaging needs to be interpreted in the appropriate clinical context.
Ultrasound: Pelvic ultrasound can assess the pelvic veins and may demonstrate dilated veins and abnormal venous reflux.
CT or MRI: Cross-sectional imaging can demonstrate pelvic varices and may identify underlying causes of pelvic venous disease, including ovarian vein reflux or compression of major abdominal or pelvic veins.
Venography: Catheter venography provides detailed assessment of the pelvic veins and venous reflux. It is usually performed when pelvic venous embolisation is being considered and allows the abnormal veins to be assessed immediately before treatment.
Treatment Options
Treatment for pelvic congestion syndrome depends on the pattern of pelvic venous disease, the severity of symptoms and whether other causes of pelvic pain have been identified.
- Conservative and medical management: For some patients, treatment may initially involve pain management or hormonal therapy, particularly when symptoms are mild or the diagnosis remains uncertain.
- Pelvic venous embolisation: For appropriately selected patients with symptomatic pelvic venous reflux, embolisation is a minimally invasive treatment that closes abnormal refluxing pelvic veins. Treatment commonly involves the ovarian veins and, when required, other pelvic veins.
- Treatment of underlying venous obstruction: In some patients, pelvic venous disease is associated with compression of major veins such as the left renal vein or left iliac vein. These findings need to be assessed individually, as treatment depends on the underlying anatomy and pattern of venous disease.
Learn more about pelvic venous embolisation