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Pelvic congestion syndrome

Pelvic congestion syndrome is a condition that results from retrograde flow through incompetent valves in ovarian veins. It is one of commonly missed and potentially treatable cause of chronic abdominal or pelvic pain. 


It tends to be more common in multiparous, premenopausal women who typically present with chronic pelvic pain for more than 6 months 1. The overall population prevalence may approach ~10%.

Clinical presentation

Patient's often have non cyclical chronic (typically dull and aching) pelvic pain. In certain cases there may be thigh or vulvar varices. It is often considered a diagnosis of exclusion.


It is considered the female equivalent to a testicular varicocele.

It is caused by:

Radiographic features

The diagnosis of pelvic congestion syndrome is established by the demonstration of multiple dilated, tortuous parauterine veins with a width greater than 4 mm or an ovarian vein diameter greater than 5-6 mm 4.

  • ovarian vein >5-6 mm (positive predictive value of 71-83%) 
  • may show multiple dilated veins in the adnexae with reversed venous flow on colour Doppler, especially after Valsalva maneuver
  • the venous calibres may increase on real time during Valsalva

Contrast enhanced CT typically shows dilated pelvic and ovarian veins. The supine position during scanning may underestimate the size of venous dilatation.

MR venography

May show dilated veins. Time of flight (TOF) imaging can be performed where contrast is not required.

Signal characteristics include.

  • T1: seen as flow voids
  • T2: mostly high signal but but can vary dependent on velocities from low signal to iso signal
  • GE: high signal  

Treatment and prognosis

Treatment options include coil embolisation of the gonadal vein: ovarian vein embolisation. Surgical (e.g. laparoscopic) ligation of the ovarian vein may also be an option in selected cases. The presence of multiple collaterals between iliac and ovarian venous plexuses may cause recurrence of symptoms.

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