Pelvic Congestion Syndrome

 

Pelvic congestion syndrome is a term used to describe a set of symptoms related to the presence of multiple varicose veins in the pelvis.

It was first described by Richet in 1857 as ovarian varicocele. It is more common during the late 20s and early 30s but could be seen in younger women.

Alleged symptoms are variable and bear little relationship to the apparent severity of the condition. Symptoms are attributed to blood

vessels ischemia, slow drainage and blood stasis, ischemia of organs being drained and release of pain mediators. Pain usually follows increased intra-abdominal pressure. It is worse while sitting or standing and lifting and could be relieved by lying down. It could as well present with   postcoital pain which could last for hours or days. It is predominantly on one side but could be bilateral. It is occasionally associated with varicose veins in the thighs, buttocks region and vagina. The   spectrum of symptoms   includes :

• Dull pelvic ache   with occasional episodes of sharp pains.
• Local aching or burning sensation in the area of the varicosities.
• Painful menstruation and low backache.
• Pain during or after sexual intercourse which could last for few hours or days.
• Increased mucoid vaginal discharge with repeated negative culture for micro organisms.
• Dysfunctional uterine bleeding

Normally the mean calibre of the ovarian vessels is 3.8 mm. This could reach 7.5 mm in case of incompetent valves. Various theories have been put forward to explain why these vessels tend to dilate but the most plausible ones are absent or incompetent venous valves and / or blood vessel wall collagen abnormalities. It was shown that 13-15% of women lack valves in the left ovarian vein in comparison to 6% on

the right side. However certain   women are more likely to show these vascular phenomena but are not all symptomatic including:

• Women with PCOS
• multiparous women
• Women with retroverted uterus

Furthermore women with pelvic congestion syndrome were described to have larger uterine cross sectional   area and thicker endometrium than other women.

Abdominal pressure at the 'ovarian points' during clinical examination could reproduce or simulates the patient's pain. It reported that such tenderness with history of postcoital pain are 94% sensitive and 77% specific for pelvic congestion.

At this point it is important to mention that   many gynaecologists do not accept this diagnosis and no specific treatment has yet been agreed upon.

 

Though venography is still the   definitive radiological investigation for patients with suspected pelvic congestion syndrome, it is not frequently used for that purpose. This could be due to the fact that the diagnosis is still not universally accepted. The dilated uterine and ovarian vessels show reduced venous clearance of the contrast medium. However with transvaginal scan examination the condition could manifest as multiple circular or elongated sonolucent areas 5 mm or more in diameter on either or both sides of the cervix. They tend to increase in size with   increased intra-abdominal pressure. With 3D technology a better visual picture could be obtained by scanning across the upper cervix and lower uterine cavity.

   

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The 3 pictures below show a rendered ultrasound view using power Doppler mapping demonstrating increased vascular markings in both broad ligaments lateral to the uterus. The neigbouring laparoscopy photographs of the same patient confirmed pelvic congestion despite the patient being in 30⁰ Trendelenberg position.

 

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Management

 

As mentioned before no specific treatment has been agreed upon. However both medical and surgical means have been used with variable results.

 

Medical treatment with 30 mg medroxyprogesterone acetate (provera) every day for 6 months has been used by many gynaecologists   to offer temporary relief from symptoms.   In fact reduction in the size of the dilated vessels has been demonstrated with venography after such treatment. One study showed 77% of patients treated demonstrated   such an effect. Since the oral contraceptive pill did not give such improvement the effect was mostly related to the anti oestrogen effect of provera rather than the actual suppression of ovulation. Unfortunately this is a temporary remedy which lasts only while using the drug. Other treatment modalities with possible good effect include psychotherapy and using dihydroergotamine.

 

Surgical treatment including ovarian vein ligation, hysterectomy with and without removing the ovaries and tubes have been reported. Almost 50% of patients did not show any response after ovarian veins ligation. As well hysterectomy did not improve symptoms unless combined with bilateral salpingo-oophorectomy. More favourable reports followed correction of uterine retroversion and catheter embolisation of the ovarian veins but more studies are needed to verify these results

 

 

 

The above 6 photographs show left pelvic sidewall varicose veins dissected and clipped. Only 7 of the clips are shown in these photographs. Varicosity could be seen lateral to the left uterosacral ligament, pelvic sidewall,   in the mesosalpinx and the left broad ligament up   and lateral to the infundibulopelvic ligament. The patient had chronic pelvic pain with no other demonstrable cause. Ultrasound scan examination revealed left side pelvic congestion which did not respond to high dose of medroxyprogesterone acetate.

 

Important point

 

I saw many patients with grossly dilated pelvic veins on both sides of the uterus who had no correlated symptoms. This is a common observation in asymptomatic patients with PCOS. It might serve a big purpose to study the biodata of symptomatic and asymptomatic patients to help in better understanding of this condition.