Pelvic congestion syndrome (some prefer pelvic venous insufficiency 9 ) is a condition that results from retrograde flow through incompetent valves in ovarian veins resulting in pelvic varices and pelvic pain. It is a commonly missed and potentially treatable cause of chronic abdominopelvic pain.
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Terminology
The term pelvic varices is also used in the setting of dilated pelvic veins on imaging with or without the presence of pelvic pain ref.
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, leg, buttock 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 the left renal vein by SMA also known as the nutcracker phenomenon
incompetent valves in ovarian vein
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
criteria for the diagnosis of pelvic varices include a venous diameter ≥4 mm and a venous flow velocity ≤3 cm/s as well as a connection with arcuate vessels in the myometrium 14
ovarian vein >5-6 mm (positive predictive value of 71-83%)
may show multiple dilated veins in the adnexa with reversed venous flow on color Doppler, especially after Valsalva maneuver
the venous calibers may increase in 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 depending on velocities from low signal to iso signal
GE: high signal
Treatment and prognosis
Treatment options include coil embolization of the gonadal vein: ovarian vein embolization. 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 a 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 11.
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