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.

• Pain

  Causes of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000;14(3):389-402. 26. Nader A, Candido KD. Pelvic pain. Pain Pract. 2001;1(2):187-96. 27. Jung SC, Lee W, Chung JW, Jae HJ, Park EA, Jin KN, et al. [revistas.fucsalud.edu.co]

  Pelvic congestion syndrome: Etiology of pain, diagnosis, and clinical management. [mayoclinic.pure.elsevier.com]

  A 80% success rate in pain reduction has been reported, (i.e., a reduction in the quantity of pain medications that the woman requires). Pain reduction varies from complete to partial. [babymed.com]

  It is estimated that a third of all women will experience chronic pelvic pain during their lifetime. Chronic pelvic pain is defined as “non-cyclic” pain lasting greater than six months. [hopkinsmedicine.org]

  […] syndrome, Taylor's syndrome, Pelvic congestion syndrome, Congestion-fibrosis syndrome, PPS - Pelvic pain syndrome, Pelvic pain syndrome, Pelvic congestion, Pelvic congestion syndrome (disorder), congestion; fibrosis syndrome, syndrome; congestion-fibrosis [fpnotebook.com]

• 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. Pelvic examination detects tender ovaries and cervical motion tenderness. 1. Perry CP: Current concepts of pelvic congestion and chronic pelvic pain. [merckmanuals.com]

  […] standing Pain after intercourse (dyspareunia) Pain before the menstrual cycle Visible varicose veins around the vulva, vagina, inner thigh, and sometimes the buttocks and legs Painful menstruation (dysmenorrhea) Abnormal bleeding during menstruation Fatigue [westernvascular.com]

  […] much time is spent standing Pelvic pain that worsens during menstruation, after sex, or after certain physical activities Swollen vulva Varicose veins in the genital region or legs Hemorrhoids Low back pain Vaginal discharge Abnormal vaginal bleeding Fatigue [dignityhealth.org]

• Swelling

  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]

  At follow-up, the pain and swelling had resolved with hot compresses and continuation of anticoagulation therapy. [westjem.com]

  Shrinking of the venous collaterals within pubic and upper thigh regions due to better hemodynamics resulted in reduced swelling and less severe sensation of heavy legs. [mp.pl]

  When these valves do not function properly, they allow a backflow of blood to pool in the lower abdomen and pelvic region which causes the veins in these areas to enlarge and swell. [hamiltonvein.com]

  This causes blood to reflux and pool in the vein, leading to congestion and swelling. The result? Chronic pain, heaviness, and pelvic varicose veins. [vispdocs.com]

• Weakness

  Pelvic floor muscle dysfunction such as pain, spasm, tender points, trigger points, shortening, and weakness is another common finding. [pamelamorrisonpt.com]

  Once the catheter is positioned, the embolic agent (metal coil or other material) is placed to block the weak vein. The catheter is removed. The procedure typically takes about an hour. [henryford.com]

  Pelvic veins have one-way valves that stop blood from flowing the wrong way, but if they're too weak to form a proper seal, some blood may seep through and collect. This is the same issue that causes varicose veins in your legs. [vascularsurgeryassociates.net]

  As with varicose veins in the legs, varicose veins in the pelvis develop when valves in the veins become weak and don't close properly. This allows blood to flow backwards and pool in the vein, causing bulging and pain. [gwhospital.com]

  As with varicose veins in the legs, the valves in the veins that return blood to the heart become weak and do not close properly. This causes pooling of blood and bulging in the vein in the pelvis. [quadcitiesbusinessnews.com]

• Surgical Procedure

  Based upon these results, recommendation of either pharmacotherapy or other surgical procedures is difficult to justify. However, it is also clear that 6-31.8% of patients do not get substantial relief from pelvic venous embolization. [ncbi.nlm.nih.gov]

  These procedures can include: ultrasound laparoscopy (a surgical procedure that uses small cameras to look inside the pelvis) CT scan MRI scan venogram The ultrasound is often preferred as the first step in diagnosing PCS as it’s possible to detect the [healthline.com]

  Treatment approaches varied significantly between the two groups from purely conservative measures during pregnancy to surgical procedures on the ovarian and vulvar veins in group 1. [doi.org]

  More about PCS Treatment Laparoscopic Ligation Laparoscopic ligation is a surgical procedure in which a woman’s ovarian veins are tied off. It is a more difficult and invasive procedure than ovarian vein embolisation. [sydneyfibroidclinic.com.au]

  This is a non-surgical procedure that involves the radiologist injecting tiny coils and a hardening solution into the vein to collapse and permanently close it. Embolisation can often be performed at the same time as the venogram or MRI. [womhealth.org.au]

• Abdominal Pain

  The major symptoms are: low abdominal pain, dyspareunia or postcoital ache, gluteal or thigh varices, and emotional disturbances. [ncbi.nlm.nih.gov]

  Pelvic congestion syndrome (PCS) describes chronic lower abdominal pain due to proximal venous insufficiency in the abdomen or pelvis. The PCS score is used to determine the probability of the presence of PCS. [inanutshell.ch]

• Abdominal Bloating

  Other symptoms may include fatigue, mood swings, headaches, and abdominal bloating. Pelvic examination detects tender ovaries and cervical motion tenderness. 1. Perry CP: Current concepts of pelvic congestion and chronic pelvic pain. [merckmanuals.com]

  Other symptoms may include lower back and leg pain, watery discharge from the vagina and exhaustion, as well as mood swings and abdominal bloating. [miamiveincenter.com]

  bloating, and fatigue Diagnosis of PCS While doctors didn’t always know about PCS or didn’t look for the condition in the past, PCS often went unnoticed. [mintstl.com]

  Abdominal bloating or tenderness in the abdominal area. An irritable bladder or bowel. Discomfort during sexual intercourse. [usavascularcenters.com]

• Lower Abdominal Pain

  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]

  Pelvic congestion syndrome (PCS) describes chronic lower abdominal pain due to proximal venous insufficiency in the abdomen or pelvis. The PCS score is used to determine the probability of the presence of PCS. [inanutshell.ch]

  Beard RW, Reginald PW, et al. (1988) Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynecol 95:153–161 Google Scholar 16. [link.springer.com]

  Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol. 1988;95(2):153-61. 29. Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. [revistas.fucsalud.edu.co]

• Abdominal Tenderness

  Common Signs of Pelvic Congestion Syndrome: Leg, pelvic and/or buttock pain, aching or cramping Pelvic discomfort and fullness throughout the month Pelvic bloating Pain and/or aching with and/or after intercourse Pelvic and/or abdominal tenderness Symptoms [windsongradiology.com]

• 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]

  Pain is usually unilateral and worsened by standing and by sexual intercourse; other symptoms include low back pain, leg pain, and sometimes abnormal menstrual bleeding. Try treating with medroxyprogesterone acetate, NSAIDs, or GnRH agonists. [merckmanuals.com]

  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]

  Pelvic or low back pain that increases after long periods of sitting or standing Pain after intercourse (dyspareunia) Pain before the menstrual cycle Visible varicose veins around the vulva, vagina, inner thigh, and sometimes the buttocks and legs Painful [westernvascular.com]

  Case 2: Back pain A 34-year-old female with 3 children by Cesarean section presented with an 8 year history of back pain. [f1000research.com]

• Low Back Pain

  Pain is usually unilateral and worsened by standing and by sexual intercourse; other symptoms include low back pain, leg pain, and sometimes abnormal menstrual bleeding. Try treating with medroxyprogesterone acetate, NSAIDs, or GnRH agonists. [merckmanuals.com]

  Pelvic or low back pain that increases after long periods of sitting or standing Pain after intercourse (dyspareunia) Pain before the menstrual cycle Visible varicose veins around the vulva, vagina, inner thigh, and sometimes the buttocks and legs Painful [westernvascular.com]

  The pain is also worse during or after sexual intercourse. It is often accompanied by low back pain, aches in the legs, and abnormal vaginal bleeding. The pain tends to occur only on one side. [msdmanuals.com]

• Buttock Pain

  Common Signs of Pelvic Congestion Syndrome: Leg, pelvic and/or buttock pain, aching or cramping Pelvic discomfort and fullness throughout the month Pelvic bloating Pain and/or aching with and/or after intercourse Pelvic and/or abdominal tenderness Symptoms [windsongradiology.com]

• Irritability

  Women may also notice changes in their urinary and bowel habits, including a worsening of existing stress incontinence or irritable bowel syndrome symptoms. [bbc.com]

  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]

  Women suffering from this condition usually report a dull-achy pain in their abdomen that is irritated by prolonged periods of standing and during or after intercourse. Although the cause is unknown, PCS affects over 15% of all women. [sonoranvein.com]

  Discomfort during or after sexual intercourse Irritable bladder that may lead to stress incontinence Irritable bowel (recurring pain in the abdomen and diarrhea alternating with constipation) Varicose veins at the top of the inner thighs Bulging veins [mintstl.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]

• 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]

  […] are 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 and gynecological symptoms in women with irritable bowel syndrome. J Psychosom Obstet Gynaecol. 1996 Mar; 17(1):39-46. 6. Cheong Y, William Stones R. Chronic pelvic pain: aetiology and therapy. [revistas.fucsalud.edu.co]

  pelvic congestive syndrome, pelvic pain syndrome, Taylor's syndrome, Pelvic congestion syndrome, Congestion-fibrosis syndrome, PPS - Pelvic pain syndrome, Pelvic pain syndrome, Pelvic congestion, Pelvic congestion syndrome (disorder), congestion; fibrosis [fpnotebook.com]

  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]

• 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]

  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]

  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]

  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]

  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]

• Dyspareunia

  Sometimes the pain is accompanied by dyspareunia, urinary urgency or constipation. [ncbi.nlm.nih.gov]

• 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]

  Green-top Guideline n 41 Reiter RC (1990) A profile of women with chronic pelvic pain. Clin Obstet Gynecol 33(1):130–136 Article CAS PubMed Google Scholar Ahangari A (2014) Prevalence of chronic pelvic pain among women: an updated review. [link.springer.com]

  Pelvic congestion syndrome: A condition in which there is congestion of blood in dilated veins of the pelvis. The ovarian vein and internal iliac veins are commonly affected, and the congestion may lead to chronic pelvic pain in women. [medicinenet.com]

• Dysmenorrhea

  Family members also have dysmenorrhea. [merckmanuals.com]

  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]

  Among them, 10 patients with dysmenorrhea needed revision of the cupping session once, while 5 patients with CPP required a third session in order to achieve complete relief of pain. [omicsonline.org]

  Symptoms like chronic pain, pain during sexual intercourse, and dysmenorrhea can lead to a decrease in physical activity, loss of function, and depression. [healthline.com]

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.

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.

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].

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.

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.

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.

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

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.

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.

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