Pelvic congestion syndrome

Pelvic congestion syndrome (PCS) is a poorly understood and often overlooked etiology of chronic pelvic pain. Millions of women worldwide may develop chronic pelvic pain at some time in their life, and the occurrence may be as high as 39.1%.

Chronic pain caused by Pelvic Congestion Syndrome can be debilitating and accounts for 10% to 15% of all gynecologic visits. Once identified, PCS can be treated successfully with embolization therapy.

The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don’t close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms. Pelvic congestion syndrome is unusual in women who have not been pregnant. Studies show 30 percent of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15 percent have PCS along with another pelvic pathology.

Risk Factors

  • Two or more pregnancies and hormonal increases
  • Fullness of leg veins
  • Polycystic ovaries
  • Hormonal dysfunction

Symptoms

The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:

  • Following intercourse
  • Menstrual periods
  • When tired or when standing (worse at end of day)
  • Pregnancy

Other symptoms include:

  • Irritable bladder
  • Abnormal menstrual bleeding
  • Vaginal discharge
  • Varicose veins on vulva, buttocks or thigh.
Pelvic Congestion Syndrome CLIS Beirut

MRI of the pelvis showing dilated tubular structures around the uterus and ovaries.

Diagnosis Of Pelvic Congestion Syndrome

Once other abnormalities or inflammation has been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods. Dr. Abbas Chamsuddin will use the following imaging techniques to confirm pelvic varicose veins that could be causing chronic pain.

Pelvic venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, the doctor examines patients on an incline, because the veins decrease in size when a woman is lying flat.

MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels.

Pelvic ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done is an very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.

Transvaginal ultrasound: This technique is used to see better inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems. Transvaginal ultrasound is helpful in identifying ovarian cysts or uterine leiomyomas.

Pelvic Congestion Syndrome Embolyzation

Treatment Of Pelvic Congestion Syndrom

After the diagnosis of PCS has been identified, medical treatment with non-steroidal anti-inflammatory drugs may help relieve the patient’s pain for the short term. Analgesia is a good first-line option, but if symptoms do not improve, an interventional radiology procedure should be made.

In this procedure, Dr Chamsuddin inserts a thin catheter, about the size of a strand of spaghetti, into the femoral vein in the groin and guides it to the affected vein using X-ray guidance. To seal the faulty, enlarged vein and relieve painful pressure, the doctor inserts tiny coils and plugs often with a sclerosing agent (the same type of material used to treat varicose veins) to close the vein.

After treatment, women are discharged home the same day and able to return to regular activity the next day. Some patients may experience some mild cramping for 24 to 48 hours, which is managed well with ibuprofen.

Efficacy

In addition to being less expensive to surgery and much less invasive, embolization offers a safe, effective, minimally invasive treatment option that restores patients to normal. The procedure is very commonly successful in blocking the abnormal blood flow. It is successfully performed in 95-100 percent of cases. A large percentage of women have improvement in their symptoms, between 85-95 percent of women are improved after the procedure. Although women are usually improved, the veins are never normal and in some cases other pelvic veins are also affected which may require further treatment.

OUTCOME

Embolization is successful in 98% to 100% of all PCS cases, with recurrence rates of less than 8%. Symptom improvement has been documented in 70% to 85% of women studied and can be expected within two to four weeks post procedure. Long-term follow-up data are minimal.

Because it can negatively affect the quality of life and personal relationships of women and result in physical and psychological suffering, chronic pelvic pain is a significant health problem for many women. Patients with chronic pelvic pain report a high incidence of anxiety, depression and physical worries.

Pelvic Congestion Embolization offers a safe, effective and minimally invasive treatment option that can improve or resolve symptoms in women with chronic pelvic pain caused by PCS.

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