Pelvic Congestion Syndrome

Indications

It has been estimated that almost 40% of all women will experience chronic pelvic pain during their lifetime and that 15% of all women between the ages of 18-50 experience chronic pelvic pain.  Of note, 15% of all hysterectomies and 35% of all diagnostic laparoscopies are performed due to chronic pelvic pain.  Ovarian vein incompetence has been shown to occur in approximately 10% of women.  This phenomenon can lead to the pelvic congestion syndrome and its associated symptoms in 60% of these patients.  Despite this incidence, pelvic congestion syndrome is significantly under-diagnosed.  It typically results in pelvic pain that is often described as dull and aching.  The pain is typically worse in an upright position and becomes more severe with walking and postural changes.  It may be associated with dyspareunia or a post-coital ache. 

The symptoms of pelvic congestion syndrome (PCS) consist of a generalized achiness in their pelvic area, especially when standing, lifting, or after sexual intercourse. The symptoms are typically caused by the development of varicosities in the genital area of women. More specifically, these varices occur in the infundibulopelvic and broad ligaments within the pelvis.  The exact reason as to why these varicosities develop is unknown but one important factor is the absence or incompetence of valves in the ovarian veins.  There is likely an anatomic component to this as well since reflux occurs more often on the left than the right. This may be due to the fact that valves are absent more often on the left than the right but is also likely due to the fact that the left ovarian vein drains into the left renal vein before draining into the IVC while the right ovarian vein drains directly into the IVC.  This may explain why symptoms are often more common or more severe on the left side than the right. A hormonal component is also felt to contribute to the development of PCS as well since it mainly affects premenopausal women.  The pain associated with pelvic congestion syndrome has been directly attributed to the presence of these dilated veins within the pelvis.

When symptoms suggest this problem, patients will often have an ultrasound or CT scan.  Both of these tests allow for visualization of the varicose veins within the pelvis and can potentially identify an enlarged ovarian vein. The best test for confirming the diagnosis is a pelvic venogram.  This is a procedure done as an outpatient in one of our partner hospitals.  A mild sedative is given.  A small catheter is placed into the vein in the right groin.  X-rays are used to guide the catheter into the ovarian and internal iliac veins that drain the pelvis. X-ray dye is then injected into the catheter to generate an image of the veins in the pelvis. This enables us to know if the veins are enlarged and if flow in these veins is abnormal. When the procedure is over, the catheter is removed.  Usually patients have to recover for about an hour after the procedure before they can go home.  Patients can resume all their normal activities the next day.

Procedural Details

Once a patient has been diagnosed with pelvic congestion syndrome, it is important to direct treatment towards blocking flow in the abnormal ovarian vein(s). The treatment involves blocking blood flow in the abnormal veins, which is known as embolization. By embolizing the veins which are not functionally normally, flow is directed into normal veins. This reduces pressure in the pelvic veins, which eliminates the development of the varicosities and the pain that they cause. This procedure is done as an outpatient in one of our partner hospitals.  A mild sedative is given.  A small catheter is placed into the vein in the right groin.  X-rays are used to guide the catheter into the veins that drain the pelvis.  Metallic coils are placed in the veins to block the flow.  Sometimes other agents are used which are irritating to the vein and cause them to close down.  When the procedure is over, the catheter is removed.  Usually patients have to recover for about an hour after the procedure before they can go home.  Patients can resume all their normal activities the next day.  Some patients will experience pelvic pain for up to a week after the procedure.  We usually manage this pain with over the counter medications. 

Results

For several decades, this treatment has been associated with good clinical outcomes in most women suffering from the symptoms of pelvic congestion syndrome.  Currently, this procedure is technically successful in almost 100% of patients.  Symptomatic improvement tends to be seen in >80% of patients undergoing embolization. Edward described the first report of transcatheter embolization of the ovarian veins in 1993. Since that time, several studies have been published demonstrating the success of embolization at addressing the pain associated with Pelvic Congestion Syndrome.  

Most of the studies published to date involve the embolization of one or both ovarian arteries without embolization of one or both internal iliac veins.   While largely positive in terms of outcomes, this data demonstrates the shortcomings of this approach.  For example, Capasso, et al reported on ovarian vein embolization in 19 patients (13 underwent unilateral ovarian vein embolization and 6 underwent bilateral ovarian vein embolization).  After a mean of 15.4 months follow-up, significant relief was experienced in 57.9%, partial relief in 15.8%, and no relief in 26.3% of patients.  Similarly, Kwon, et al described their experience with ovarian vein embolization in 67 patients (unilateral embolization in 65 patients; unilateral embolization in 2 patients).  They found significant relief in 82%, no relief in 15%, and worsening symptoms in the remaining 3% of patients.  Studies evaluating ovarian vein embolization for PCS by Cordts, et al and Tarazov, et al have had similar findings [28,29].  Importantly, while the use of isolated ovarian vein embolization still provides most patients with significant symptomatic improvement, the percentage of patients who do not respond seems to support the addition of internal iliac venography and embolization to a treatment protocol. 

In general, the addition of internal iliac venography and embolization as well as the addition of sclerotherapy to the embolization technique has improved the results of this procedure.  Venbrux, et al described their experience in 56 patients, with all patients undergoing bilateral ovarian vein embolization and 43 patients undergoing internal iliac vein embolization.  Procedures in this study were performed with coils and a sclerosant.  After a mean follow-up period of 22.1 months, significant or partial relief was seen in 96% of patients while 4% of patients experienced no improvement in their symptoms.  Similarly, Kim, et al reported their experience with 127 patients (106 undergoing bilateral ovarian vein embolization, 20 undergoing unilateral ovarian vein embolization, and 108 undergoing internal iliac vein embolization) treated with coils and sclerosants.  They found significant relief in 85%, no relief in 12%, and worsening symptoms in 3% of their patients after a mean follow-up of 45 months.  In 2013, Laborda, et al. published the largest study evaluating ovarian and internal iliac vein embolization for PCS.  202 patients with chronic pelvic pain were treated with coil embolization, leading to clinical success in 93.9% of patients after 5 years (179 patients completed the 5-year follow-up period); 33.5% of patients reported complete disappearance of their symptoms after embolization.  Other reports by Mowatt, et al, Sichlar, et al, van der Vleuten, et al, Edo Prades, et al, and Maleux, et al, have reported similar data to the studies outlined above. 

Chung and Hugh published a randomized study supporting the use of embolization in the treatment of PCS in 2003.  They evaluated 106 patients with PCS and pelvic pain who were initially treated unsuccessfully with medroxyprogesterone.  These patients were randomly assigned to three treatment groups: ovarian vein embolization with coils (n=52), hysterectomy with bilateral salpingo-oophorectomy and hormone replacement therapy (n=27), and hysterectomy with a unilateral salpingo-oophorectomy on the affected side (n=27).   All patients underwent venography before treatment to confirm the diagnosis of pelvic congestion syndrome.  Based on the use of a visual analog scale to assess pain, embolization was significantly more effective at reducing pelvic pain compared to the other methods of treatment.

References