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Pelvic Congestion Syndrome

Pelvic Congestive Syndrome

Pelvic congestion syndrome (PCS) is a condition often seen in multiparous women of premenopausal age, and is characterized by chronic pelvic pain and dyspareunia associated with pelvic varicosities.


Presentation

PCS may present with a variety of symptoms which may be nonspecific. Pelvic pain and postcoital ache, particularly on the left side, are the most classic symptoms of PCS. Patients may experience an acute and severe pelvic fullness or a chronic and dull pain. Pain may worsen with sitting, standing, or just before menstrual periods. Women with PCS may have other nonspecific symptoms like pelvic tenderness, lethargy, depression, vaginal discharge, dysmenorrhea, rectal discomfort or an increase in frequency of urination. Patients may present with tenderness over the ovaries or uterus during physical examination. Pelvic fullness, ovarian tenderness and chronic pain are the specific manifestations of PCS.

Fatigue
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019[patientslikeme.com]
  • Other symptoms may include fatigue, mood swings, headaches, and abdominal bloating.[merckmanuals.com]
  • […] congestion syndrome have a larger uterus and a thicker endometrium. 56% of women manifest cystic changes to the ovaries, and many report other symptoms, such as dysmenorrhea, back pain, vaginal discharge, abdominal bloating, mood swings or depression, and fatigue[en.wikipedia.org]
  • Other symptoms include generalized fatigue, depression, abdominal or pelvic tenderness, lumbosacral neuropathy, rectal pain, and urge to urinate.[pamelamorrisonpt.com]
  • Effie’s personal tubal ligation story Four days after her tubal ligation, she experienced lower back pain, pelvic pressure, insomnia, nausea, joint pain in the knees and ankles, fatigue, and anger.[tubal-reversal.net]
Abdominal Pain
  • The major symptoms are: low abdominal pain, dyspareunia or postcoital ache, gluteal or thigh varices, and emotional disturbances.[ncbi.nlm.nih.gov]
  • Twenty-three cases presented abdominal pain after procedure. In 24 patients (12.5%), there was recurrence of their leg varices within the follow-up. The mean degree of patients' satisfaction was 7.4/9.[ncbi.nlm.nih.gov]
  • All had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Embolization was performed with a mixture of enbucrilate and lipiodized oil in all but one patient, in whom enbucrilate and minicoils were used.[ncbi.nlm.nih.gov]
  • Patients usually complain of lower abdominal pain that has lasted for more than six months, is intermittent or continuous, and may become worse during menses or after a hard day's work.[ncbi.nlm.nih.gov]
  • Signs that you may be experiencing Pelvic Congestion Syndrome include: Lower back and abdominal pain during menstruation, following intercourse, when you’re tired or standing up at the end of the day, and during pregnancy.[miamiveincenter.com]
Regurgitation
  • We present a female patient who had pelvic congestion syndrome caused by inferior vena cava reflux associated with tricuspid regurgitation, but without other symptoms or signs related to her tricuspid regurgitation.[ncbi.nlm.nih.gov]
Back Pain
  • This case study shows how aorto-left renal vein fistula in a female can present with left-sided pelvic pain secondary to ovarian vein reflux, a symptom of pelvic congestion syndrome, next to typical features such as epigastric and back pain.[ncbi.nlm.nih.gov]
  • The first three weeks, I had a lot of back pain, similar to how I felt with the first surgery, I had a bout of indigestion and some acne. Then, after the third week, the back pain went away, as did the indigestion and acne, joint pain and insomnia.[tubal-reversal.net]
  • It is often accompanied by low back pain, aches in the legs, and abnormal vaginal bleeding. Some women occasionally have a clear or watery discharge from the vagina. Other symptoms may include fatigue, mood swings, headaches, and abdominal bloating.[merckmanuals.com]
  • Polycystic ovaries Hormonal dysfunction Symptoms Dull, aching pain in the lower abdomen and lower back Pain that increases after intercourse, menstrual periods, when tired or when standing and during pregnancy Irritable bladder Abnormal menstrual bleeding[holyname.org]
  • Other symptoms include a lack of energy, depression, rectal discomfort and chronic lower back pain.[cirse.org]
Low Back Pain
  • It is often accompanied by low back pain, aches in the legs, and abnormal vaginal bleeding. Some women occasionally have a clear or watery discharge from the vagina. Other symptoms may include fatigue, mood swings, headaches, and abdominal bloating.[merckmanuals.com]
  • Making the diagnosis more challenging is the vast array of the associated symptoms, including cyclic pain (with menstrual periods), dyspareunia, bladder irritability, GI symptoms and low back pain.[clinicaladvisor.com]
  • Prior to this report, the symptoms of PCS were mainly thought to be intra-pelvic, with the exception of low back pain and varicose veins, along with their associated symptoms.[doi.org]
  • back pain, aches in the legs, and abnormal vaginal bleeding Occasionally a clear or watery discharge from the vagina Sometimes fatigue, mood swings, headaches, and bloating A doctor’s examination Ultrasonography or specialized imaging techniques Sometimes[merckmanuals.com]
  • back pain, iliac fossa vein, and groin pain can easily be imagined to be a result of pelvic varicose veins, due to their anatomical association, a recent report of two patients with severe hip pain being cured with pelvic vein embolization has shown[indjvascsurg.org]
Irritability
  • Both patients underwent PVE and reported 'miraculous' resolution of left hip pain and also PCS symptoms including pelvic pain, irritable bowel issues and the disappearance of pelvic dragging, with almost immediate disappearance of vulval and vaginal varicosities[ncbi.nlm.nih.gov]
  • Sclerosing agents (chemicals that provide irritation or inflammation) are injected into the pelvic varicose veins, and small metal coils or plugs are placed to block flow into the ovarian vein.[vein.stonybrookmedicine.edu]
  • An irritable bowel is also common, alternating with constipation. Some women experience deep discomfort during intercourse. Still, others have varicose veins that appear on the vulva or vagina, on the back of the thighs and on the inner thighs.[myvivaa.com]
  • Indeed, one described the change as ‘miraculous’ and reported complete resolution of irritable bowel symptoms (diarrhoea and urgency) which she had previously not given any heed to and assumed to be normal following pregnancy.[doi.org]
  • Other symptions include: A dull, aching pain in the lower abdomen and lower back that comes after intercourse, during their menstrual cycles, after standing and during pregnancy Related signs include an irritable bladder, abnormal menstrual bleeding,[gwhospital.com]
Insomnia
  • Effie’s personal tubal ligation story Four days after her tubal ligation, she experienced lower back pain, pelvic pressure, insomnia, nausea, joint pain in the knees and ankles, fatigue, and anger.[tubal-reversal.net]
  • […] outlined below: Tenderness upon deep palapation of the ovarian point [1] Dyspareunia [1] Presence of varicose veins in the buttock and/or lower extremities [1] Headache [1] Gastrointestinal pain/discomfort [1] Changes in bowel and bladder [1] Fatigue [1] Insomnia[physio-pedia.com]
Pelvic Pain
  • Chronic pelvic pain, defined as lower abdominal or pelvic pain for a duration of 6 months or more, causes significant morbidity and results in a large number of diagnostic laparoscopies.[ncbi.nlm.nih.gov]
  • The optimal diagnostic approach for PCS-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are urgently needed for PCS-associated pelvic pain.[ncbi.nlm.nih.gov]
  • In the third group, 12 women with pelvic congestion syndrome and chronic pelvic pain used only the Class II compression stockings. The treatment continued for 14 days. A clinical criterion was the change of severity of chronic pelvic pain.[ncbi.nlm.nih.gov]
  • Seventeen patients reported a reduction in pelvic pain after the first embolization and three patients reported a reduction in pelvic pain after the second embolization.[ncbi.nlm.nih.gov]
  • As such, it is challenging but important to determine which patients have chronic pelvic pain specifically related to pelvic congestion syndrome in order to treat them properly.[ncbi.nlm.nih.gov]
Dyspareunia
  • Sometimes the pain is accompanied by dyspareunia, urinary urgency or constipation.[ncbi.nlm.nih.gov]
  • Venous angioplasty and stenting provide excellent short-term results for such patients, with resolution of chronic pelvic pain and dyspareunia.[ncbi.nlm.nih.gov]
  • PCS is a chronic pain syndrome characterized by positional pelvic pain that is worse in the upright position and is associated with pelvic and vulvar varicosities as well as symptoms of dyspareunia and postcoital pain.[ncbi.nlm.nih.gov]
  • After the treatment, all subjects experienced a dramatic decrease in pelvic pain, as well as an improvement in two or more preexisting symptoms, including extremity swelling, dyspareunia, external varicosities, constipation, and emotional disturbance.[ncbi.nlm.nih.gov]
  • Manifestations may include pelvic pain, dyspareunia, dysuria, and dysmenorrhea as well as external varices and a number of psychosocial symptoms.[ncbi.nlm.nih.gov]
Vaginal Discharge
  • With pelvic congestion there is a lot of pain and a generally very heavy feeling.Symptoms are stomach cramps,backache ,pain ful gas,ibs symptoms,increased vaginal discharge,achey legs and some swelling down below.x[patient.info]
  • Women with PCS may have other nonspecific symptoms like pelvic tenderness, lethargy, depression, vaginal discharge, dysmenorrhea, rectal discomfort or an increase in frequency of urination.[symptoma.com]
  • discharge or visible varicose veins on the vulva, buttocks or thighs Diagnosis and Treatment Doctors can diagnose pelvic congestion syndrome with the following tests: Pelvic venography: Interventional radiologists perform a venogram by injecting dye[gwhospital.com]
  • Abnormal menstrual bleeding Vaginal discharge Varicose veins on the vulva, buttocks or thighs Irritable bladder Additionally, there are certain risk factors that can make women more susceptible to developing Pelvic Congestion Syndrome such as: Having[miamiveincenter.com]
  • Pelvic Congestion Syndrome Pelvis Chronic pain Irritable bladder Abnormal menstrual bleeding Vaginal discharge Varicose veins on vulva, buttocks or thigh Ovarian and pelvic varicose veins Overview Chronic Pelvic Pain in Women It is estimated that one-third[nm.org]
Dysmenorrhea
  • Manifestations may include pelvic pain, dyspareunia, dysuria, and dysmenorrhea as well as external varices and a number of psychosocial symptoms.[ncbi.nlm.nih.gov]
  • Associated symptoms (dysmenorrhea, dyspareunia, urinary urgency, and lower limb symptoms) were also evaluated. Patients were followed up for 12 months. RESULTS: The technical and clinical success was 100%.[ncbi.nlm.nih.gov]
  • It may also manifest with dysmenorrhea, and post coital pain. About 10% of the women in the general population have ovarian varices, of which 60% may develop this syndrome.[symptoma.com]
  • Family members also have dysmenorrhea.[merckmanuals.com]
  • Women with pelvic congestion syndrome have a larger uterus and a thicker endometrium. 56% of women manifest cystic changes to the ovaries, and many report other symptoms, such as dysmenorrhea, back pain, vaginal discharge, abdominal bloating, mood swings[en.wikipedia.org]
Pelvic Pain in Women
  • Pelvic venous insufficiency (PVI), defined as retrograde flow in the gonadal and internal iliac veins, is the underlying cause of pelvic congestion syndrome (PCS), a common cause of disabling chronic pelvic pain in women of child-bearing age.[ncbi.nlm.nih.gov]
  • PURPOSE: Pelvic congestion syndrome is an uncommon poorly understood and frequently misdiagnosed disorder of the pelvic venous circulation, which causes chronic pelvic pain in women in premenopausal age.[ncbi.nlm.nih.gov]
  • The ovarian vein and internal iliac veins are commonly affected, and the congestion may lead to chronic pelvic pain in women. The pain is usually dull, varies in severity, and is not related to the menstrual cycle.[medicinenet.com]
  • Pelvic Congestion Syndrome Pelvis Chronic pain Irritable bladder Abnormal menstrual bleeding Vaginal discharge Varicose veins on vulva, buttocks or thigh Ovarian and pelvic varicose veins Overview Chronic Pelvic Pain in Women It is estimated that one-third[nm.org]
  • Answer: Pelvic congestion syndrome is a common cause of ongoing pelvic pain in women under the age of 45 who have experienced two or more pregnancies.[womhealth.org.au]

Workup

Definitive diagnosis of PCS is often a challenge and may take a long time for many patients. Interventional radiology helps in evaluation of the condition once other pelvic causes are ruled out. Many traditional imaging techniques may miss diagnosis of PCS as venous distention may not be clear or may be absent in the image. Ultrasound with Doppler imaging provides a good image of venous blood flow in the pelvic region [8]. Doppler diagnosis is used when the ovarian veins are greater than 4 mm in diameter, and there is a retrograde blood flow in left ovarian vein [9]. MRI is yet another imaging modality primarily used in the diagnosis of PCS. This imaging is also very sensitive in locating and assessing pelvic varices.

Laparoscopy is a method for direct visualization of the varices and helps to rule out other causes of chronic pelvic pain like endometriosis. But in many patients, laparoscopy may not give a positive image. Pelvic venogram gives information on dynamic blood flow along with measurements of both ovarian and pelvic veins [10]. Diagnostic venogram also has the benefit of performing embolotherapy as a treatment, when needed. A transfundal pelvic venogram, in which a catheter is placed into the myometrium, shows venous abnormalities in the uterus. But ovarian and pelvic varices may be missed in the venogram.

Treatment

Pharmacological treatment options often try to address the chronic pain associated with PCS. Pain relief may be obtained by non-steroidal anti-inflammatory drugs. Other medical treatment methods include progestins, danazol, phlebotonics, dihydroergotamine, and hormone replacement therapy. Medroxyprogesterone acetate is used to increase venous contraction.

Extraperitoneal resection of the left ovarian vein is the surgical method used to improve symptoms of PCS [11]. Hysterectomy is useful in relieving the symptoms to a certain extent, but 33% of the patients were reported to have residual pain after the treatment. Laparoscopic ligation of ovarian veins is a popular treatment option, but has the disadvantages of significant morbidity, and hospital stay for the procedure. Pelvic vein embolization therapy is effective in reducing morbidity associated with surgery. This procedure has become more popular as the accepted treatment modality for treating PCS [12].

Some of the possible complications associated with embolization include coil migration, renal vein thrombosis, and perforation of ovarian vein. Chances of recurrence can be reduced by using bilateral venography and embolization of both ovarian and iliac veins. Often treatment is done in a staged way starting with embolization of right and left ovarian varices followed by pelvic varices after about a month.

Prognosis

PCS may cause distress to many women. None of the treatment modalities currently used are fully successful in treating the condition. Chronic pain may cause anxiety, depression, and physical worries [5]. Endovascular treatment has a good prognosis when compared to many other treatment options. Laparoscopic ligation of ovarian veins results in remission of pain and reduced pelvic varicosities for about a year [6]. But surgical management elevates the risk of pelvic adhesion formation, and thus increases morbidity. Ovarian and pelvic venous embolization gives a good prognosis [7].

Etiology

Multiple factors are thought to be involved in the etiology of this syndrome. PCS may be classified on the basis of variations in etiology. This includes PCS caused by:

  • Anatomic dysfunction
  • Psychosomatic dysfunction
  • Hormonal dysfunction
  • Latrogenically induced dysfunction
  • Neuropathic dysfunction

An incompetent venous valvular system in the pelvis causes stasis, congestion and pain that are characteristic of this syndrome. It is reported that pregnancy induces an increase in the capacity of ovarian veins up to 60 times the normal. This may continue for more than six months postpartum and makes pregnancy one of the major risk factors for developing this syndrome. Uterine malposition is also considered as a possible etiology of PCS by anatomic dysfunction.

Studies show that stress affects the functioning of smooth muscle and secretory cells leading to psychosomatic effects. These lead to chronic congestion of vessels and, ultimately, PCS. PCS of psychosomatic origin was supported by studies that showed patients with this syndrome tend to be more neurotic than normal women.

Women with PCS were found to have many other hormonally induced conditions like multicystic ovaries, larger uterus, and thicker endometrium [2]. This indicates the possibility of the condition being triggered by hormonal dysfunction. Hormonal changes lead to alterations in intraluminal pressure leading to weakening of ovarian vein walls. Valvular incompetence of this kind plays a key role in development of congestion and valvular stasis.

Intrauterine devices used in contraception and tubal sterilization procedures are both presumed to be associated with the development of PCS. In one of the studies, about 60% of the patients with PCS were found to have undergone tubal ligation process earlier [3]. Malformed vessels of PCS produce neurotransmitters which are considered to be responsible for the development of this syndrome.

Epidemiology

PCS is more commonly seen in women of reproductive age, particularly those below the age of 45 years. Pregnancy increases the risk of ovarian congestion and, thus, PCS. The syndrome is rarely found in women who have not been pregnant. About 30% of the women with chronic pelvic pain is diagnosed with PCS, and the pain is caused exclusively by the condition. About 15% of patients with chronic pelvic pain have PCS along with other pelvic pathology. Ovarian varices are also an important risk factor in the development of PCS. About 60% of the patients with ovarian varices develop this syndrome.

Sex distribution
Age distribution

Pathophysiology

Pathogenesis of PCS is multifactorial. Deficiency in the valves of the ovarian veins is one of the key factor that lead to pathogenesis of this syndrome. Many hormonal and mechanical factors contribute to the development of pelvic varices, a major etiological factor of PCS. Both ovarian and pelvic varices result in the chronic, dull aching pain characteristic of PCS.

Multiple previous pregnancies often lead to an increase in intravascular volume and vein capacity to over 60%. Distention of veins results in incompetent valves. Pregnancy is also associated with weight gain and changes in the pelvic structure, both of which result in venous obstruction. This leads to accumulation of blood in the veins resulting in engorgement and clotting. Nerves in the surrounding tissues are affected and pain ensues [4].

Estrogen, the main female hormone, is known to weaken the walls of veins. Thus, levels of estrogen in the body, particularly in premenopausal women, is presumed to be associated with the syndrome. Retroaortic left renal vein causes obstruction in left ovarian vein and pelvic varices. Pelvic varices may also result from compression of the left common iliac vein against the spine.

Vein congestion may be caused secondarily by portal hypertension, increased flow of blood in the pelvic veins, and vascular malformations. Pelvic varices are formed by portosystemic shunt in portal hypertension. Pelvic tumors may occasionally cause ovarian vein distention by venous outflow obstruction or by an increase in the flow of blood.

Prevention

Controlling the risk factors associated with the condition is the only known preventive measure for PCS.

Summary

Pelvic congestion syndrome (PCS) is a common condition often seen in multiparous women of premenopausal age. It is characterized by chronic pelvic pain and dyspareunia associated with the presence of ovarian and pelvic varicosities. Both hormonal and mechanical factors play and important etiological role in the development of varicosities. Blood flow through the congested veins of pelvis region results in chronic pain, pressure and heaviness. It may also manifest with dysmenorrhea, and post coital pain.

About 10% of the women in the general population have ovarian varices, of which 60% may develop this syndrome [1]. Imaging techniques are used to locate and evaluate the dilated and tortuous uterine and ovarian vessels, which extend to the side walls of the pelvis. Some of the major risk factors of the syndrome include two or more pregnancies, and hormonal dysfunction. Embolization is considered to be a safe and effective way to treat PCS.

Patient Information

Pelvic congestion syndrome (PCS) refers to the condition caused by the presence of varicose veins in ovary or pelvis. It is characterized by a chronic, dull pain in the pelvis which may increase with standing for a long time. PCS is a common gynecologic problem seen in women in reproductive age. Both mechanical and hormonal factors are known to cause this syndrome. Some of the factors that increase the chances of developing PCS include hormonal changes, previous multiple pregnancies, polycystic ovaries, and fullness of leg veins.

Chronic, dull pain in the pelvic region is the classic, characteristic symptom of this condition. The pain may be felt in the lower abdomen and lower back. It may increase during menstrual periods, after intercourse, after standing for a long time, and during pregnancy. Other symptoms of PCS are not so specific and includes increased frequency of urination, abnormal bleeding during menstrual periods, vaginal discharge, and presence of varicose veins in vulva and buttocks. A thorough pelvic examination will help in ruling out the chances of other diseases that may lead to chronic pain. Imaging techniques are used to confirm the diagnosis of PCS. The techniques include pelvic venography, in which a dye is injected into the veins to make them visible during X-ray. MRI is also used in diagnosing the affected veins in PCS. Pelvic and transvaginal ultrasound are other techniques commonly used in locating and assessing the condition.

Embolization is a minimally invasive procedure in which a catheter is inserted into the vein and directed to affected vein using imaging methods. Tiny coils are inserted into the affected vein to relieve the pressure inside the vessel. Other treatment methods depend on the symptoms. Analgesics are recommended to reduce the pain. Hormonal therapy is suggested in some cases to control the symptoms. Other surgical options include hysterectomy with removal or tying of affected veins. Of the different methods, embolization is considered to be a safe and effective method to treat PCS.

References

Article

  1. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87(3):321-327.
  2. Adams J1, Reginald PW, Franks S, Wadsworth J, Beard RW. Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion. BR J Obstet Gynaecol. 1990;97(7):583-587.
  3. El-Minawi MF, Mashhor N, Reda MS. Pelvic venous changes after tubal sterilization. J Reprod Med. 1983;28(10):641-648.
  4. Stones R W. Pelvic vascular congestion: half a century later. Clin Obstet Gynecol. 2003;46(4):831–836.
  5. Walling M K, Reiter R C, O'Hara M W, et al. Abuse history and chronic pain in women: prevalences of sexual abuse and physical abuse. Obstet Gynecol. 1994;84:193–199.
  6. Gargiulo T, Mais V, Brokaj L, Cossu E, Melis G B. Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Laparosc. 2003;10(4):501–504.
  7. Kim H S, Malhotra A D, Rowe P C, Lee J M, Venbrux A C. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17:289–297.
  8. Park S J, Lim J W, Ko Y T, et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol. 2004;182(3):683–688.
  9. Beard R W, Highman J H, Pearce S, et al. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 1984;2:946–949.
  10. Venbrux A C, Lambert D L. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome). Curr Opin Obstet Gynecol. 1999;11:395–399.
  11. Rundqvist E, Sandholm L E, Larsson G. Treatment of pelvic varicosities causing lower abdominal pain with extraperitoneal resolution of left ovarian vein. Ann Chir Gynaecol. 1984;73:339–341.
  12. Edwards R D, Robertson J R, MacLean A B, Hemmingway A P. Case report: pelvic pain syndrome – successful treatment of a case by ovarian vein embolization. Clin Radiol. 1993;47:429–431.

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Last updated: 2019-07-11 20:26