Keywords
pelvic venous insufficiency - pelvic congestion syndrome - chronic pelvic pain - embolization
Introduction
Chronic pelvic pain (CPP) is defined as pain in the pelvis for greater than 6 months duration that is not exclusively cyclical or post coital.[1]
[2] CPP can be caused by many different etiologies including endometriosis, fibroids, malignancy, adenomyosis, uterine prolapse, irritable bowel syndrome, dilated/incompetent pelvic veins, or even psychiatric causes.[3] This often leads to difficulty in diagnosis and subsequent treatment. CPP is a common problem among women of childbearing age with a reported incidence 24 to 39.1%[4]
[5]
[6] leading to 10 to 40% of gynecology visits.[1]
[7] Despite the high incidence, studies have shown that a large percentage of women (40–75%) do not seek medical consultation despite their symptoms.[4]
[8] One study showed that 60% of women who were seen by their general practitioner for CPP did not have any further referral or work-up.[9] Even for those patients who do seek medical consultation the work-up of CPP can be challenging which may lead to a delay or lack of diagnosis and treatment.
Pelvic venous insufficiency or pelvic congestion syndrome (PCS) is the result of insufficiency of the gonadal and/or pelvic veins. PCS is often seen in multiparous women due to increased blood volume and dilatation of the ovarian and pelvic veins during pregnancy, as well as compression by the gravid uterus. This leads to irreversible dilatation and valve damage causing reflux.[10] Additionally, 15% of women lack valves in the ovarian veins which also pre-disposes these vessels to reflux.[11] PCS has also been associated with compression of central veins in the setting of Nutcracker syndrome, with compression of the left renal vein by the superior mesenteric artery, or May–Thurner, with compression of the left common iliac vein by the right common iliac artery.[2]
[12]
[13]
Originally considered a diagnosis of exclusion, the diagnosis of PCS requires appropriate imaging and clinical findings; however, it is not always considered and evaluated during the work-up of CPP. Symptoms of PCS include dull aching pain in the pelvis which can be worse with walking, standing, or prolonged sitting, and at the end of the day. The pain can be worse during menses, intercourse, or post-coital.[14] Prominent varices on the perineum, buttock, and extremities can be seen. Other associated symptoms are vague and overlap with other etiologies of CPP, further causing a diagnostic dilemma. These include bloating, lethargy, depression, abdominal/pelvic tenderness, rectal discomfort, urinary frequency, vaginal discharge, or even lumbosacral neuropathy.[2]
[15]
Given the challenge in elucidating the underlying cause or causes of CPP, these patients are often not referred for follow-up and evaluation. The purpose of our longitudinal study was to correlate the clinical symptoms of patients with computed tomography (CT) imaging findings suggestive of PCS. Anticipating that many of these patients may suffer from CPP but are not being referred for further work-up and evaluation of PCS, we also tracked the referral and follow-up patterns.
Materials and Methods
A retrospective longitudinal review was performed at our tertiary-care hospital. This study was approved by the institutional board review at the institution and performed in compliance with the Health Information Portability and Accountability Act. All female patients aged 18 to 70 years who underwent a CT or computed tomography angiography of the abdomen and pelvis from March 2015 to March 2018 for which the final CT dictation included the terms “pelvic” plus “congestion,” “varices,” or “vein dilation” were pulled from the picture archiving and communication system (PACS). Exclusion criteria included duplicate exams, patients who had already undergone intervention for PCS, findings of venous congestion elsewhere (hepatic, rectal, mesenteric stranding, etc.), imaging findings that were not consistent with PCS or gonadal/pelvic vein dilation despite mention in the dictation, or studies with notation of findings negative for PCS ([Fig. 1]).
Fig. 1 Detailed flowchart of included and excluded patients.
̀The electronic medical record (EMR) was reviewed, and data was collected regarding patient demographics, clinical presentation, prior symptoms, imaging findings, ordering study provider, and any follow-up referral or interventions for CPP or PCS. Patient age, body mass index (BMI), parity and menstruation status were obtained. Symptoms associated with PCS including CPP, pelvic pressure, dyspareunia, acute pelvic pain (<6 months), back pain, menorrhagia, lower extremity varices, and vulvar varices were documented. Additionally, imaging findings including location of dilated veins, findings suggestive of nutcracker, or other gynecologic pathology were documented. The ordering department and reason for the exam were noted. Finally, it was documented whether pelvic pain or the potential diagnosis of PCS was addressed in follow-up via attendance at a subsequent appointment or referral to a specialist (ob/gyn, interventional radiology, or vascular surgery). Findings of this longitudinal study are descriptive and therefore no statistical analysis was applied.
Results
There were 197 studies which met the search criteria. Subsequently 101 were excluded given the exclusion criteria described above. The included patient population demographics (n = 96) are described in [Table 1], with an average age of 47 years and average BMI of 19.3 kg/m2. The majority were premenopausal (43 of 67 patients with documented menopausal status) and parous (50 of 57 patients with documented parity). Only 68 patients had documentation of the presence or absence of symptoms classically associated with PCS in the EMR; 54 of these patients endorsed one or more symptom. Pelvic pain (<6-month duration) and back pain were the most common symptom documented in the EMR. The indication for imaging studies is shown in [Table 2]; most studies were obtained for abdominal pain. “Other” reasons for the imaging includes trauma, DVT, and aortic disease.
Table 1
Patient characteristics
|
Age @ imaging (years)
|
46.9
|
|
BMI @ imaging (kg/m2)
|
19.3
|
|
Menopause (n = 67)
|
|
|
Pre
|
64% (n = 43)
|
|
Post
|
36% (n = 24)
|
|
Gravidity (n = 57)
|
|
|
G0
|
12% (n = 7)
|
|
G1+
|
88% (n = 50)
|
|
Delivery (n = 49)
|
|
|
Vaginal
|
8% (n = 4)
|
|
Cesarean
|
25% (n = 12)
|
|
Not reported
|
67% (n = 33)
|
|
Clinical symptoms (n = 54)
|
|
|
Chronic pelvic pain
|
n = 9
|
|
Pelvic pressure
|
n = 3
|
|
Dyspareunia
|
n = 8
|
|
Pelvic pain (<6 mo)
|
n = 22
|
|
Back pain
|
n = 33
|
|
Menorrhagia
|
n = 17
|
|
Lower extremity varies
|
n = 3
|
|
Vulvar varices
|
n = 3
|
|
Imaging findings (n = 96)
|
|
|
Right dilated pelvic veins
|
n = 3
|
|
Left dilated pelvic veins
|
n = 35
|
|
Bilateral dilated pelvic veins
|
n = 58
|
|
Nutcracker
|
n = 8
|
|
Other ob/gyn pathology
|
n − 11
|
Table 2
Indication for CT study
|
Indication
|
n = 96
|
|
Abdominal pain, lower
|
26%
|
|
Abdominal pain, upper
|
9%
|
|
Abdominal pain, nonfocal
|
16%
|
|
Cancer (surveillance, staging)
|
27%
|
|
GU symptoms
|
4%
|
|
Pelvic/vulvar varicosities
|
2%
|
|
Oher
|
16%
|
The majority of patients had dilated pelvic veins bilaterally (n = 58) while 35 patients had isolated left gonadal or pelvic varices. Only three patients had isolated right pelvic varices; one had varices seen originating from the right common femoral extending to the right labia without dilatation of the ovarian vein, one had isolated varices in the right broad ligament, and the last had portal hypertension, chronic portal vein occlusion, and large portosystemic collaterals involving the right ovarian vein but not the left.
The ordering department of the included imaging studies, as well as subsequent referrals is described in [Table 3]. Emergency and primary care providers accounted for approximately half of imaging orders (38 and 17%, respectively), but a variety of other providers, ranging from oncologists to gastroenterologists, also ordered studies. Only 20 of 96 patients with imaging suggestive of PCS were referred to one or more providers for follow-up to address these imaging findings. The vast majority (85%) of these patients were referred to ob/gyn. Only two patients were referred to interventional radiology ([Fig. 2]), while another four were referred to vascular surgery.
Table 3
Ordering department and subsequent patient referral for PCS
|
Ordering (n = 96)
|
Referral (n = 20)
|
|
Emergency Department
|
38%
|
–
|
|
Primary care
|
17%
|
10%
|
|
Ob/Gyn
|
3%
|
85%
|
|
Radiology
|
2%
|
10%
|
|
Vascular surgery
|
–
|
20%
|
|
Other
|
41%
|
15%
|
Fig. 2 Images obtained from a premenopausal multiparous female initially evaluated for pelvic pain (pressure sensation improved with standing, dyspareunia). Patient was referred to our group by an outside Ob/Gyn provider. (A) CT abd/pelvis w IV contrast shows multiple dilated and tortuous parametrial veins, present bilaterally but more significant on the left. (B) Venogram shows prominent pelvic collateral vessels and reflux. (C) Post coiling venogram demonstrates occlusion of the ovarian vein without reflux.
Discussion
CPP is a common problem in menstruating women that leads to a large number of gynecology referrals. It is difficult to diagnose and treat due to the many differing etiologies. CPP not only causes physical pain and discomfort but also can cause great psychological stress due to the negative connotations and stereotypes associated with pelvic pain. CPP due to ovarian varicosities was first reported in 1958.[16] PCS is CPP characterized by pressure, aching, or heaviness in the pelvis that worsens with standing, dyspareunia, and dysmenorrhea.
The work-up for PCS is difficult as the imaging findings alone are not diagnostic but suggestive or confirmatory in the appropriate clinical setting. While venography is considered the gold-standard, often CT, MRI, or ultrasound are used to suggest a diagnosis of PCS with findings of dilated gonadal and parametrial vessels. On CT the pelvic varicosities will appear as dilated, tubular, enhancing parametrial structures. One proposed diagnostic criteria on CT is at least four ipsilateral pelvic varicosities measuring >4 mm diameter or dilation of the ovarian vein of >8 mm diameter,[17] however, this is rarely used in practice and findings are often described subjectively.[15]
Conservative treatment of PCS with medication can be attempted; gonadotropin-releasing hormone analogs or medroxyprogesterone acetate have been utilized with the intent to reduce hormonal changes and subsequent fluctuation of vascular flow; however, relief is usually temporary.[2] Surgical treatment for PCS includes hysterectomy and laparoscopic ligation of the ovarian veins. Although logically resection of the uterus should remove the source of pain, studies have shown that 33% of women report residual pain and 20% of women have recurrent pain after hysterectomy.[18]
[19] Literature supporting ligation of the ovarian vein is limited to case reports and small case series.[20]
[21]
[22]
[23]
While there is a lack of randomized controlled trials and high-quality data, there is a consistent evidence published across multiple different specialties suggesting that embolization of dilated or refluxing gonadal and pelvic veins is efficacious at relieving pain symptoms in PCS patients with low rates of complications and high technical success. Two recent literature reviews published in 2016, one looking at 20 studies with 1,081 patients[24] and another with 20 case series including 1,308 patients,[25] showed significant relief in patient symptoms with low rates of complications. Recurrence rates are reported at 8%.[15] Gynecology literature also supports embolization for PCS for example, one study reports technical and clinical success rate of 100% as defined by the visual analog scale.[26] The most recent clinical practice guideline from the American Venous Forum also supports ovarian vein embolization as a treatment for PCS.[27]
We found that only 71% (68 of 96) of patients with imaging evidence of PCS had documentation of evaluation of symptoms that can be seen in the setting of PCS. Of those patients, 79% (54 of 68) had positive findings of one or more symptoms of PCS. This indicates two things; first, these patients are often not being evaluated for symptoms that can be caused by PCS. This may be related to the reason for the CT scan. For example, an oncology follow-up study may not necessarily trigger a clinician to ask about symptoms of CPP. However, these findings are in line with literature showing that women do not always seek care for CPP. A U.S. population-based study showed that 75% of women with bothersome CPP had not seen a health care provider for these symptoms.[8] The second factor is that imaging findings alone are not sufficient to diagnose PCS. Anatomical studies have shown that valves are absent in 15% of left and 6% of right ovarian veins with incompetent valves in 41% of left and 46% of right ovarian veins.[28] As venous capacity of the pelvic veins can increase over 60-fold during pregnancy, ovarian and pelvic varicosities are frequently seen in multiparous women.[29]
[30] Women may have incidentally noted pelvic varicosities without clinical symptoms consistent with PCS. In these cases, no further work-up would be indicated.
However, of the 54 patients with imaging findings and history suggestive of PCS only 20 patients were subsequently referred for further work-up. The most common referral was to ob/gyn (n = 17). This is appropriate as there are many etiologies for CPP and a complete multi-disciplinary work-up should be obtained even when PCS is suspected. However, only two patients out of the 54 were referred to interventional radiology. Both of these women subsequently underwent successful embolization. None of the patients referred to vascular surgery (n = 4) underwent intervention with the surgeons. This lack of referral demonstrates the continued challenge posed by lack of knowledge and awareness of PCS and potential treatment options. This highlights a need for outreach by interventional radiologists to referring providers who are ordering these imaging studies, as well as to patients.
Conclusion
CPP is a common cause of morbidity in women. Our longitudinal study demonstrated that while imaging findings are seen in women even without documented symptoms we are failing to capture and triage a large number of patients with both imaging and clinical symptoms of PCS. Radiologists can play a key role in the care and triage of these patients. Via increased awareness and outreach, we have the opportunity to intervene and relieve the symptoms of many patients.
