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Pelvic Congestion Syndrome

 

Submitted by Yasmin Chaudhri, MD

 

         Common cause of chronic pelvic pain

         Frequency

o       Approximately 10% of the general female population may have pelvic varices, and 60% of those women may develop this syndrome

         Clinical Symptoms

o       Chronic dull pelvic pain, pressure, and heaviness

o       Often associated with movement, posture, and activities that increase abdominal pressure

o       Unilateral or bilateral

o       Often asymmetric

o       Physical examination findings

         Varicose veins and ovarian point tenderness

         Pathophysiology

o       Probably multifactorial and may include:

o       Dilated and tortuous ovarian veins secondary to retrograde flow through incompetent valves

o       Obstructing anatomic anomalies

         Retroaortic left renal vein

         Left ovarian vein congestion due to compression of the left renal vein by the superior mesenteric artery (nutcracker phenomenon)

         Right common iliac vein compression

         Secondary congestion can be seen in various disorders including:

         Valvular incompetence

         Portal hypertension

         Acquired inferior vena cava syndrome

         Risk Factors

o       Hereditary factors

o       Hormonal influence

o       Pelvic surgery

o       Retroverted uterus

o       History of varicose veins

o       Multiple pregnancies

         Imaging Findings

o       Venography

         Direct visualization of dilated pelvic veins

o       Transvaginal Ultrasound:

         Identification of multiple dilated structures around the uterus and ovaries with venous blood Doppler signal

         Dilated pelvic vein with a diameter greater than 4 mm

         Slow blood flow (about 3 cm/sec)

         Dilated arcuate vein in the myometrium communicating between bilateral pelvic varicose veins

         More than 50% of women have associated cystic ovaries

 

 

CT (top) and Color Doppler Ultrasound (bottom) of pelvis. CT of the pelvis with intravenous contrast
shows multiple, dilated and tortuous pelvic veins (red arrows) near the patient's uterus on the patient's left side. Color Doppler ultrasound of the same area demonstrates extensive venous blood Doppler signal

Click here for this photo without annotations

 

 

 

o       MR Imaging:

         Dilated, tortuous, enhancing tubular structures near the uterus and ovary; may see extension to the broad ligament and pelvic sidewall

         T1-weighted images: varices appear as flow voids

         Gradient-echo MR: varices have high signal intensity

         T2-weighted images: usually varices appear low in signal intensity

         3D T1 gradient-echo sequences with gadolinium: varices have high signal intensity

         Treatment

o       Medical Treatment

         May be used for underlying disorders

o       Procedural Treatments:

         Laparoscopic transperitoneal ligation of ovarian veins

         Percutaneous coil embolization of the gonadal vein

         Interventional stent placement for anatomic anomalies