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 may 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 ischaemia, slow drainage and blood stasis, ischaemia of organs being drained and release of pain mediators. Pain usually follows increased intra-abdominal pressure. It is worse while sitting, standing and lifting but may be relieved by lying down. It may as well present with postcoital pain which may last for hours or days. It is predominantly on one side but can 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 may last for few hours or days.
  • Increased mucoid vaginal discharge with repeated negative culture for micro organisms.
  • Abnormal uterine bleeding

Normally, the mean calibre of the ovarian vessels is 3.8 mm. This may 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 has been 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 may reproduce or simulate the patient's pain. Such tenderness with history of postcoital pain were reported to be 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 may 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.

More dilated vessels are usually seen on the left side, as shown by the first image below. With 3D technology, increased vasculature of the uterus itself may be seen as depicted in the second image below. At the same time a better visual picture may be obtained by scanning across the upper cervix and lower uterus. This may show dilated vessels on both sides of the cervix and lower uterus, as shown by the 3D power Doppler image below.

   


The three images shown below belong to one patient who presented with pelvic ache, persistent mucoid vaginal discharge, dysmenorrhoea and postcoital pain.
  • The first colour Doppler image shows increased vascular markings on the right side of the cervix, contrary to what is usually seen in patients with pelvic congestion syndrome.
  • The second power Doppler image shows very vascular area between the bladder, urethra and the vagina. This may prove to be important information when dealing with patients booked for pelvic surgery.
  • The third power Doppler image shows very increased vascularity of the uterus reaching down to the endometrial line, despite the image being acquired immediately after menstruation.




This case demonstrated that pelvic congestion may affect all pelvic organs. Also note the very thin endometrium, despite the common observation that women with pelvic congestion syndrome usually have thick endometrium, hence their liability to abnormal uterine bleeding.




    The neighbouring image, on the other hand, shows
    increased vascular markings in the rectovaginal 
    septum [between the vagina anterioly and the rectum
    posteriorly] without the need to use colour Doppler. 
    Opposite to the previous case, there was no increased
    bladder bed vascularity. This patient presented with 
    vague dull perineal aching premenstrually and 
    increased vaginal discharge. It was not possible to 
    correlate the ultrasound findings and symptoms as 
    cause and effect. She had lower limbs varicose veins.

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


Management

 

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

 

Medical treatment


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 oral contraceptive pills did not give such improvement, the effect was mostly related to the anti oestrogen effect of provera rather than 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


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 first row of the above 6 laparoscopy shots show left pelvic sidewall varicose veins dissected and clipped. The second row show dissection and clipping of the left ovarian vein in the left infundibuloplevic ligament. Only few of the clips are shown in these shots. Varicosity can be seen lateral to the left uterosacral ligament in the 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 may serve a big purpose to study the biodata of symptomatic and asymptomatic patients, to help with better understanding of this condition.       
 
 
  Site Map