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
