Pelvic congestion syndrome can cause chronic pelvic pain, but it’s sometimes missed even when the tell-tale grape-like veins around the ovaries and uterus show up on imaging, says vascular surgeon Dr Shannon Thomas of the University of New South Wales and Prince of Wales Hospital.

Pelvic varices (abnormally dilated veins in the pelvis) may be misdiagnosed entirely, or missed when they occur alongside other causes of pelvic pain, he says.

Pelvic congestion syndrome is still poorly understood, but Dr Thomas says it “is being increasingly recognised in the literature as a cause of chronic abdominal pain, chronic pelvic pain, lower limb swelling and varicose veins.”

Once diagnosed, he says it’s relatively simple to treat.

Risk factors

Risk factors for pelvic congestion syndrome include a family history of the condition, and previous pelvic pain from other causes, Dr Thomas says.

Pelvic congestion syndrome can also result from pregnancy, Dr Thomas says. “Multiparous women have a higher risk of developing it.” This may be because pregnancy disturbs pelvic venous valve function, he says.

Several factors can cause pelvic varices to progress to pelvic congestion syndrome, such as:

• Anatomic dysfunction: incompetent valves cause stasis and congestion in the pelvic veins
• Orgasms and sexual stimulation: stimulation increases pelvic blood flow and can lead to pelvic congestion and discomfort
• Psychosomatic dysfunction: there is a complex relationship between psychological state and chronic pain
• Hormonal dysfunction: a higher incidence of varices alongside multi-cystic ovaries, enlarged uterus or thickened endometrium.
• Iatrogenic causes: IUD and tubal ligation patients have higher rates of pelvic congestion syndrome

While there is evidence that pelvic congestion syndrome is more common in women with IUDs, that link is “chicken and egg,” Dr Thomas says. The evidence is not yet clear whether IUDs themselves cause congestion, or simply that women with chronic pelvic pain are more likely to have an IUD placed.

Diagnosis of pelvic congestion syndrome

Pelvic congestion should be considered in patients with chronic pelvic pain when other diagnoses have not been found, as well as in those who aren’t responding to treatment.

It’s increasingly recognised that pelvic pain may often be multifactorial, Dr Thomas explains.

“There is a subset of patients with chronic pelvic pain who may or may not have had a history of endometriosis or an alternative diagnosis, where they essentially have pelvic congestion syndrome,” he says.

In patients with endometriosis or other diagnoses whose pain is refractory to treatment, Dr Thomas recommends looking for pelvic congestion.

Pelvic congestion is sometimes an apparently incidental finding on ultrasound when the clinicians are looking for something else.

“If you have a patient who appears to be refractory to treatment for their endometriosis or whatever other diagnosis they’ve been given, and if their imaging shows that they’ve got dilated veins in their pelvis, then it is a diagnosis that needs to be considered,” Dr Thomas says.

On the other hand, pelvic varices may be asymptomatic – and it’s important to note that they do not require further investigation if the patient is not in pain, Dr Thomas adds.

Signs and symptoms of pelvic congestion include:

• Left-sided flank pain/ left iliac fossa pain (although pain may occur anywhere in the abdominopelvic cavity)
• Pain that is intermittent
• Pain that becomes worse with standing, walking, prolonged sitting, sexual intercourse or high intensity sport, potentially leading to avoidance of these activities
• Lower back pain
• Heavy periods and severe period pain one week before menses
• Haematuria and urinary frequency and urgency
• Pelvic floor dysfunction
• Haematuria if the renal vein is compressed (nutcracker syndrome)
• Transvaginal imaging showing grape-like veins around the ovary and uterus

Symptoms often greatly improve when women are no longer having periods, such as during pregnancy or with menopause. There’s no evidence that pelvic congestion syndrome causes infertility, Dr Thomas says.

Management

A patient with suspected pelvic congestion syndrome still needs to be worked up by a gynaecologist to exclude other concomitant causes of pelvic pain, Dr Thomas says.

The vascular surgeon will be able to order specific imaging, including pelvic dopplers and abdominal CT or MR Venogram, to plan treatment of the varices themselves.

First line treatments are analgesia, physiotherapy and hormonal therapy, Dr Thomas says. However, many patients have already tried and failed these treatments by the time he meets them.

This is when minimally invasive interventional options such as coil embolisation or stenting may be considered, he says. “The technology now is allowing us to treat people without doing a massive laparotomy and surgical vessel reconstruction/ligation.”

However, Dr Thomas says it can be difficult to know who will respond to treatment. He recommends referral to a practitioner who works within a multidisciplinary team.

“The first question is, is intervention appropriate? This doesn’t follow Occam’s razor. It’s really hard to define patients who are going to benefit from treatment compared to those who won’t. You really need a multidisciplinary assessment for that,” Dr Thomas explains.

Likewise, multi-modal treatment after the procedure, and appropriate follow-up to see if there are still other causes that need to be addressed, are also crucial for the patient to recover functionally, he adds. Patients may benefit from pelvic physiotherapy, psychological therapy, ongoing pain management, and/or hormonal treatment that requires involvement of other healthcare practitioners.

Key takeaways

• Consider pelvic congestion syndrome in refractory pelvic pain.
• Pelvic pain is common and often multifactorial – Occam’s razor usually does NOT apply.
• Size and extent of varices does not predict pain, and vice versa.
• Don’t assume the sonographer is looking for it, and don’t assume the gynaecologist is considering it – ideally this needs to be on the GP’s radar.