Pelvic Congestion Syndrome (PCOS) is one of the known causes of chronic pelvic pain. Chronic pelvic pain is pain that has been present for more than 6 months and affects 15% of women. Of these 30% are due to underlying pelvic congestion.
What does Pelvic Congestion Syndrome mean?
Pelvic congestion syndrome is due to varicose veins within the pelvis – usually originating from the ovarian veins. The veins become enlarged or dilated within the pelvis causing symptoms.
What are symptoms of pelvic congestion syndrome?
- Non-cyclical, positional lower back, pelvic and upper thigh pain
- Difficult or painful sexual intercourse
- Difficult or painful urination
- Symptoms worsen throughout the day and are exacerbated by activity or prolonged standing.
- Pain relieved by lying down.
- High thigh veins, groin veins, vulval veins, veins underneath buttocks
Who typically gets pelvic congestion syndrome?
- Women of childbearing age 20-40
- Usually having borne more than one child
- Usually slim
How is pelvic congestion syndrome diagnosed?
As there are many causes for pelvic pain, one should be fully examined by a gynaecologist to exclude common causes such as:
- Pelvic Inflammatory Disease
Pelvic veins can often be seen by Duplex Doppler ultrasound. This is a non-invasive test that looks at the flow of blood. It is similar to having a scan done when one is pregnant and involves placing gel on the thighs and lower abdomen and scanning. It is not painful and has no risk of radiation.
Most of the time, the diagnosis needs to confirmed by a CT Venogram (CAT scan) or MR Venogram. This is slightly more invasive in that a drip must be put up and a dye injected in order to create a vein map, so that veins can be measured, organs assessed and appropriate treatment be planned.
The treatment of PCOS usually involves a surgical intervention called: Ovarian Vein Embolisation.
Medical treatment with hormones can be tried but have varying results and patients do not often want to chronically be on these treatments.
It is important to elicit the extent of pain as many patients suffer from chronic pain syndrome where the biology of perceiving and responding to pain has been altered resulting in hypersensitivity and hyperresponsiveness.
The treatment of choice would be ovarian vein embolization and at this setting the internal iliac veins should be assessed for incompetency as well.
Ovarian Vein Embolisation
The treatment of Pelvic Congestion Syndrome (PCOS) involves treating the ovarian veins. The veins are usually enlarged causing backflow of blood into the pelvis, with resultant varicose veins in the pelvis. This causes all the pelvic symptoms. Occasionally the pressure can decompress down into the legs, and the patient will present with leg varicose veins and no pelvic symptoms.
The management involves an operation - coils are used to block the ovarian veins. This is an operative procedure that involves inserting a sheath into the femoral vein in the groin or the jugular vein in the neck and doing a venogram (similar to a coronary angiogram, but imaging the pelvic and ovarian veins).
If the ovarian veins are enlarged or prominent then they will be sealed off by inserting coils into them that cause then to thrombose or block off. Foam sclerotherapy will be inserted into the pelvic varices to seal them off as well.
The internal iliac veins may be assessed for reflux and according to tributaries affected, may be sclerosed with foam sclerotherapy or coils as above.
Is the treatment successful?
Reports of the success of treatment can be quite varied with studies showing 47% – 94% showing some improvement in pain. Often a multidisciplinary team is necessary for more holistic and compete management and this can include specific pain management with a pain specialist. However, the underlying cause does need to be addressed.