Clinical Presentation, Patient Assessment, Anatomy, Pathophysiology, and Imaging of Pelvic Venous Disease

Sean Maratto; Neil M. Khilnani; Ronald S. Winokur

doi:10.1055/s-0041-1729745

Seminars in Interventional Radiology, Table of Contents

Semin intervent Radiol 2021; 38(02): 233-238
DOI: 10.1055/s-0041-1729745

Review Article

Clinical Presentation, Patient Assessment, Anatomy, Pathophysiology, and Imaging of Pelvic Venous Disease

Authors

Sean Maratto

¹Division of Interventional Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Neil M. Khilnani

²Division of Interventional Radiology, Weill Cornell Vein Treatment Practice, New York – Presbyterian Hospital/Weill Cornell Medicine, New York, New York
Ronald S. Winokur

¹Division of Interventional Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

Abstract

Pelvic venous disorders (PeVDs) can result in several different clinical presentations, but can be challenging to distinguish from other etiologies of chronic pelvic pain (CPP). Clinical evaluation of CPP patients optimally should be performed in a multidisciplinary fashion and patients who may have PeVD should be referred for consultation with a vascular interventionalist whose evaluation would utilize an imaging workup to search for pelvic varices. Additionally, it is critical to quantify the quality-of-life effects of all CPP to determine the impact on the patient's overall health. Diagnostic imaging, including transabdominal and transvaginal ultrasound, computed tomography, magnetic resonance imaging, and venography, can be utilized to identify pelvic varices, as well as venous reflux and obstruction leading to CPP. The use of the SVP tool is important to classify PeVD patients based on their clinical symptoms, varicose veins, and pathophysiology for precise clinical communication and for reporting clinical research. The goal of this publication is to delineate the clinical presentation, anatomy, pathophysiology, and imaging evaluation of patients with CPP suspected of having PeVD.

Keywords

pelvic venous disease - pelvic congestion - diagnostic imaging - interventional radiology

Full Text

References

References
1 Stones RW, Price C. Health services for women with chronic pelvic pain. J R Soc Med 2002; 95 (11) 531-535
2 Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. BMJ 2006; 332 (7544): 749-755
3 Edwards RD, Robertson IR, MacLean AB, Hemingway AP. Case report: pelvic pain syndrome--successful treatment of a case by ovarian vein embolization. Clin Radiol 1993; 47 (06) 429-431
4 Cordts PR, Eclavea A, Buckley PJ, DeMaioribus CA, Cockerill ML, Yeager TD. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization. J Vasc Surg 1998; 28 (05) 862-868
5 Beinart C, Sniderman KW, Tamura S, Vaughan Jr ED, Sos TA. Left renal vein to inferior vena cava pressure relationship in humans. J Urol 1982; 127 (06) 1070-1071
6 Sulakvelidze L, Tran M, Kennedy R, Lakhanpal S, Pappas PJ. Presentations in women with pelvic venous disorders differ based on age of presentation. Phlebology 2020; 36 (02) 135-144
7 Eklof B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. American Venous Forum, European Venous Forum, International Union of Phlebology, American College of Phlebology, International Union of Angiology. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg 2009; 49 (02) 498-501
8 Lurie F, Passman M, Meisner M. et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord 2020; 8 (03) 342-352
9 Black CM, Thorpe K, Venrbux A. et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol 2010; 21 (06) 796-803
10 Khilnani NM, Meissner MH, Learman LA. et al. Research priorities in pelvic venous disorders in women: recommendations from a multidisciplinary research consensus panel. J Vasc Interv Radiol 2019; 30 (06) 781-789
11 Knuttinen MG, Zurcher KS, Khurana N. et al. Imaging findings of pelvic venous insufficiency in patients with postural orthostatic tachycardia syndrome. Phlebology 2021; 36 (01) 32-37
12 Hytten F. Blood volume changes in normal pregnancy. Clin Haematol 1985; 14 (03) 601-612
13 Santoshi RKN, Lakhanpal S, Satwah V, Lakhanpal G, Malone M, Pappas PJ. Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2018; 6 (02) 202-211
14 Antignani PL, Lazarashvili Z, Monedero JL. et al. Diagnosis and treatment of pelvic congestion syndrome: UIP consensus document. Int Angiol 2019; 38 (04) 265-283
15 Cura M, Cura A. What is the significance of ovarian vein reflux detected by computed tomography in patients with pelvic pain?. Clin Imaging 2009; 33 (04) 306-310
16 Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol 1988; 95 (02) 153-161
17 Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim MD, Nicolini PH, Pabon-Ramos WM, Greenblatt M. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disorders 2021; 9 (03) 568-584 . Doi: 10.1016/j.jvsv.2020.12.084. Epub 2021 Jan 30. PMID 33539720
18 Labropoulos N, Jasinski PT, Adrahtas D, Gasparis AP, Meissner MH. A standardized ultrasound approach to pelvic congestion syndrome. Phlebology 2017; 32 (09) 608-619
19 Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 2018; 97 (07) 776-786
20 Park SJ, Lim JW, Ko YT, Lee DH, Yoon Y, Oh JH. et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol 2004; 182: 683-688
21 Giacchetto C, Cotroneo GB, Marincolo F, Cammisuli F, Caruso G, Catizone F. Ovarian varicocele: ultrasonic and phlebographic evaluation. J Clin Ultrasound 1990; 18 (07) 551-555
22 Balian E, Lasry JL, Coppé G. et al. Pelviperineal venous insufficiency and varicose veins of the lower limbs. Phlebolymphology 2008; 5: 17-26
23 Hiromura T, Nishioka T, Nishioka S, Ikeda H, Tomita K. Reflux in the left ovarian vein: analysis of MDCT findings in asymptomatic women. AJR Am J Roentgenol 2004; 183 (05) 1411-1415
24 Awad AS, Taha MMM, Manaf MHA. et al. Role of multi-detector CT venography in evaluation of pelvic congestion syndrome. Egypt J Radiol Nucl Med 2020; 51: 159
25 Rozenblit AM, Ricci ZJ, Tuvia J, Amis Jr ES. Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. AJR Am J Roentgenol 2001; 176 (01) 119-122
26 Kuo YS, Chen CJ, Chen JJ. et al. May-Thurner syndrome: correlation between digital subtraction and computed tomography venography. J Formos Med Assoc 2015; 114 (04) 363-368
27 Dick EA, Burnett C, Anstee A, Hamady M, Black D, Gedroyc WM. Time-resolved imaging of contrast kinetics three-dimensional (3D) magnetic resonance venography in patients with pelvic congestion syndrome. Br J Radiol 2010; 83 (994) 882-887
28 Yang DM, Kim HC, Nam DH, Jahng GH, Huh CY, Lim JW. Time-resolved MR angiography for detecting and grading ovarian venous reflux: comparison with conventional venography. Br J Radiol 2012; 85 (1014): e117-e122
29 Meneses LQ, Uribe S, Tejos C, Andía ME, Fava M, Irarrazaval P. Using magnetic resonance phase-contrast velocity mapping for diagnosing pelvic congestion syndrome. Phlebology 2011; 26 (04) 157-161
30 Asciutto G, Mumme A, Marpe B, Köster O, Asciutto KC, Geier B. MR venography in the detection of pelvic venous congestion. Eur J Vasc Endovasc Surg 2008; 36 (04) 491-496
31 Topolanski-Sierra R. Pelvic phlebography. Am J Obstet Gynecol 1958; 76 (01) 44-52
32 Nishimura Y, Fushiki M, Yoshida M. et al. Left renal vein hypertension in patients with left renal bleeding of unknown origin. Radiology 1986; 160 (03) 663-667
33 Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of embolization or sclerotherapy for pelvic veins for reducing chronic pelvic pain. Syst Rev 2016; 27 (10) 1478-1486