The pelvic congestion syndrome – an overview
This One-Pager provides an overview on the pelvic congestion syndrome (PCS). It reviews pathophysiology, clinical features, diagnosis and treatment options for pelvic congestions syndrome. PCS is characterized by non-visible dilated, tortuous and congested veins within the pelvis. Premenopausal multiparous women are affected most frequently. Risk factors include genetic predisposition, anatomy, pregnancy, obesity and others. Patients with PCS experience chronic pelvic pain and a variety of other symptoms. Different methods such as ultrasound, venography, CT/MRI and laparoscopy can be applied to establish the diagnosis of PCS. Pelvic congestion syndrome can be treated with percutaneous embolization, medical therapy, surgical treatment or compression therapy as conservative treatment. This content is published in English, German, French and Italian.
What is the pelvic congestion syndrome?
The pelvic congestion syndrome (PCS) is a complex condition associated with chronic pelvic pain (CPP) of more than 6 months duration and pelvic varicosities and / or pelvic venous obstruction predominantly found in premenopausal women (1). The exact pathophysiology of PCS is unclear and is most likely caused by a multifactorial combination of mechanical and hormonal factors including retrograde blood flow, venous hypertension and dilation of veins. Pelvic varicosities can also be asymptomatic, making diagnosis of PCS difficult.
Pathophysiology
Externally non-visible dilated, tortuous & congested veins develop within the pelvis
Valvular insufficiency
- Congenital absence of ovarian vein valves (13-15%)
- Valvular incompetence/dysfunction (35-40%) e.g. due to a 50-60% increase in pelvic vein capacity during pregnancy
Vein obstruction
Extrinsic compression on draining veins e.g. "Nutcracker-Syndrome" and "May-Thurner-Syndrome"
Pregnancy and hormonal changes
- Mechanical compression of uterus
- Estrogen acts as venous dilator
- Progesterone weakens venous valves
- "Free" veins not surrounded by fascia
Pelvic congestion syndrome is most frequent in multiparous women of reproductive age.
Risk Factors
- Genetic predisposition
- Anatomy
- Pregnancy
- Pelvic surgery
- Estrogen therapy
- Obesity
- Phlebitis
- Prolonged standing
- Heavy lifting
Clinical presentation & symptoms
PCS causes chronic pelvic pain and a variety of other symptoms.
Lower abdominal & pelvic pain
- Intermittent or constant
- Described as dull ache or fullness
- Persists for more than 6 months
- Often aggravated by prolonged sitting, standing & walking, coitus, menstruation and pregnancy
- Symptoms often disappear in supine position
Associated symptoms
Varicose veins of vulva, perineum, buttocks and lower extremities
Associated non-specific symptoms
Headache, bloating, nausea, vulvar swelling, vaginal discharge, backache, leg fullness, rectal discomfort, urinary urgency, irritable bowels, lethargy, anxiety and depression
Diagnostic workup
Different methods can be applied to establish the diagnosis of PCS. However, it is important to exclude other potential causes of CPP such as endometriosis, fibroids or pelvic inflammatory disease.
Ultrasound: Widely available non-invasive imaging modality to visualize the pelvic venous plexus and examination of blood flow in an upright or standing position to avoid decompression of the veins.
Venography: Catheter-directed diagnostic gold standard for PCS visualizing veins and identifi cation of incompetence, congestions and retrograde filling when PCS is suspected and noninvasive imaging is inconclusive. Enables direct
therapeutic intervention (embolization, sclerotherapy).
CT and MRI: Provide complete examination of pelvic anatomy and better imaging with spatial resolution, but do not allow for therapeutic intervention. Specificity is considered low, but can identify other causes of CPP or coexisting pathologies.
Laparoscopy: Performed as part of CPP investigation for detection of endometriosis or adhesions. Less established for PCS diagnosis. Performed in supine position, thereby overlooking pelvic varicosities.
Treatment options
Percutaneuos embolization
Medical therapy
Medroxyprogesterone acetate or gonadotropin-releasing hormone analogue goserelin are used to suppress ovarian function or increase venous contraction. There is limited data available, only few clinical trials were conducted and symptomatic relief lasts only for short time, probably due to development of resistance.
Surgical treatment
Compression therapy (2)
Conservative treatment with compression shorts, e.g. in combination with stockings can reduce CPP, improve blood flow and reduce insufficiency of perforating veins in some patients.
Take-home message
PCS is a relatively common condition in premenopausal women that needs to be considered in the differential diagnosis of CPP. If left untreated, this condition can negatively affect the quality of life with physical and psychological consequences. Recent studies suggest an association between PCS and recurring lower limb varicosities, which are related to insufficient venous function. Thus, an elaborate diagnosis with an examination in an upright position is crucial for the appropriate treatment of patients with CPP and/or recurring varicose veins.