Pelvic Congestion Syndrome (PCS) is often an overlooked and untreated condition with chronic symptoms which may include pelvic pain, perineal heaviness, urgency of micturition and post-coital pain, caused by ovarian and/or pelvic vein reflux and/or obstruction, which may be associated with vulvar, perineal, and/or lower extremity varices.
Venous hypertension is a leading factor in development of PCS which is the result of abnormal venous flow, particularly with centrifugal/ retrograde direction which develop pelvic varices due to reflux in ovarian or internal iliac vein.
Actually, we prefer to insert the condition into the “Chronic pelvic venous disorders” in which we can consider Pelvic Congestion Syndrome (PCS), nutcracker syndrome, iliac compression.
The risk factors are: 2 or more pregnancies or hormonal increases (rare in nulliparous and postmenopausal women), fullness of leg veins, Polycystic Ovaries, hormonal dysfunction.
Pelvic Congestion Syndrome is an important cause of chronic pelvic pain (CPP) in women due to pathological venous hemodynamics in ovarian and pelvic veins.
As many as 39% of women have reported experiencing pelvic pain at some time in their life.
Main clinical symptom, chronic pelvic pain, which can be exacerbated by postural changes, walking and sexual intercourse and, also, during menstruation.
Other main clinical manifestations are dispareunya, vulval and/or perineal varices. Other symptoms are varicose veins on perineal, vulval, gluteal or posterior thigh areas, dysmenorrhea, vulvar congestion, urinary frequency.
Trans-abdominal ultrasound which in most of the cases is the first step on instrumental diagnosis but trans-vaginal ultrasound is considered to be the examination of choice since it offers better visualization of the pelvic venous plexus. Catheter-directed retrograde selective venography of ovarian and internal iliac veins is method of choice when there are symptoms and there is the indication to treat the patient.
Diagnostic criteria for PCS are following:
- an ovarian vein diameter more than 6 mm with proven reflux;
- contrast retention more than 20 seconds;
- congestion of the pelvic venous plexus and/or opacification of the ipsilateral (or contralateral) internal iliac vein, or filling of vulvovaginal and thigh varicosities
Before any treatment is administered, it is important to exclude other medical conditions that may cause similar symptoms.
The choice of treatment depends on symptom severity and the presence of vulvar and lower limb varicose veins.
Initially, a medical approach should be offered, reserving endovascular treatment for petients with important symptomatology.
In the majority of women, medroxyprogesterone acetate (MPA) or goserelin acetate effectively reduced pain and the size of the varicose veins. MPA and micronized purified flavonoid fraction (MPFF) provide short-term improvement, but no data are available on their long-term efficacy.
Surgery has progressively been replaced by endovenou procedures with distal embolization of the refluxed veins using a coil and/or a foam sclerosant. In some cases it is possible to add the direct foam sclerotherapy at inguinal level to close the escape points under the guide of ultrasound.
