Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS), also known as pelvic vein incompetence or pelvic vein reflux, is a chronic medical condition in women caused by varicose veins in the lower abdomen. This condition results in chronic pelvic pain, estimated to affect one-third of women in the United States.

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Pelvic congestion syndrome is caused by dilatation of the ovarian and/or pelvic veins, causing the valves in the veins that stop the blood from flowing backwards to stop working, resulting in the pooling of blood in the veins. These pelvic varicose veins cause pressure and bulging veins in the uterus, ovaries and vulva.



Prevalence of Pelvic Congestion Syndrome

  • Women typically less than 45 years old and in their child-bearing years.
  • Chronic pelvic pain accounts for 10-15% of outpatient gynecological visits
  • Studies show 30% of women with chronic pelvic pain have PCS as a sole cause of their pain and an additional 15% have PCS with another pelvic pathology.

Risk Factors of Pelvic Congestion SyndromeRisk Factor for Pelvic Congestion Syndrome pelvic congestion syndrome Pelvic Congestion Syndrome pregnant woman silhouette Pelvic Congestion Syndrome2 200x300 

  • Women with two or more pregnancies
    • Significant increase in intravascular volume at each term of gestation
    • Vein capacity can increase by 60%
    • Over time, venous distension can cause the valves to become incompetent
    • Weight gain and anatomic changes in the pelvic structures during pregnancy may cause chronic intermittent venous obstruction
    • Endogenous estrogen is known to weaken the vein walls
  • Varicose veins in the lower extremities
  • Polycystic ovaries
  • Hormonal dysfunction

Clinical Indications for Pelvic Congestion Syndrome 

  • Chronic pain in the lower abdomen or lower back
  • Worsening pain following sitting or standing or at the end of the day
  • Worsening pain during or after intercourse
  • Worsening pain just before the onset of menses
  • Worsening pain during pregnancy
  • Varicose veins of the labia, buttocks, and lower extremities
  • May have generalized lethargy, depression, abdominal or pelvic tenderness, vaginal discharge, dysmenorrhea, swollen vulva, lumbosacral neuropathy, rectal discomfort, or urinary frequency
  • Patients with chronic pelvic pain report a high incidence of anxiety, depression and physical worries

Secondary Pelvic Congestion Syndrome from Anatomic Anomalies

  • Nutcracker Syndrome: left ovarian vein and the left renal vein are compressed by the superior mesenteric artery
  •  May-Thurner Syndrome: Compression rom the right common iliac artery on the left common iliac vein against the spine and pelvic brim can cause iliofemoral DVT as well as the pelvic varices of PCS
  •  Retroaortic left renal vein may cause obstruction of the left ovarian vein leading to symptomatic varices

Ultrasound Diagnostic Criteria for Pelvic Congestion Syndrome

The pelvic congestion syndrome ultrasound exam evaluates blood flow direction and diameter of the bilateral internal iliac veins, bilateral ovarian veins, and the left renal vein. Patency of the iliocaval veins is assessed as well as diameters of any para-uterine veins. Criteria for songraphic diagnosis of pelvic congestion syndrome include:

  • Dilated ovarian vein >6 mm in diameter
  • Retrograde venous blood flow in the left ovarian vein
  • Presence of dilated tortuous para-uterine veins
  • Evidence of secondary pelvic congestion syndrome (Nutcracker Syndrome or May-Thurner Syndrome)

Patient Preparation for a Pelvic Congestion Syndrome Ultrasound Exam

  • No food or drink (except water with medications) 8 hours prior to the PCS exam and schedule a morning appointment to reduce the amount of overlying bowel gas.
  • Full bladder: Patients should drink 24 ounces of water 30 minutes prior to the PCS exam.
  • Anti-gas over-the-counter medication: It is highly recommended that patients take an anti-gas medication prior to their appointment to reduce the amount of overlying bowel gas. (Take as directed on the package.)

Treatment for Pelvic Congestion Syndrome 

  • Medical management with hormone analogues and analgesics
  • Surgical ligation of ovarian veins
  • Hysterectomy with or without bilateral salpingo-oophorectomy
  • Percutaneous pelvic vein embolization therapy of the bilateral ovarian and internal iliac veins, and pelvic varices
    • Sclerosant foam and coils
    • Studies show 75-85% clinical success
    • Procedural technical success rates have been shown to reach as high as 99%

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