Pelvic congestion syndrome (some prefer pelvic venous insufficiency 9) is a condition that results from retrograde flow through incompetent valves in ovarian veins. It is a commonly missed and potentially-treatable cause of chronic abdominopelvic 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%.
Patients 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.
Pelvic congestion syndrome is considered the female equivalent to a testicular varicocele. It is caused by:
- venous obstruction: such as retroaortic left renal vein
- compression of left renal vein by SMA also known as nutcracker phenomenon
- incompetent valves in ovarian vein
The diagnosis of pelvic congestion syndrome is established by the demonstration of multiple dilated, tortuous parauterine veins with a width >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 adnexa with reversed venous flow on color Doppler, especially after Valsalva maneuver
- the venous calibers may increase on real time during Valsalva
- prominent myometrial veins may also be present 1-8
Contrast enhanced CT typically shows dilated pelvic and ovarian veins. The supine position during scanning may underestimate the size of venous dilatation.
May show dilated veins. Time of flight (TOF) imaging can be performed where contrast is not required.
- T1: seen as flow voids which represent engorged arcuate vessels
- T2: mostly high signal but can vary dependent on velocities from low signal to iso signal
- GE: high signal
Treatment and prognosis
Treatment options include coil embolization of the gonadal vein: ovarian vein embolization. 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.
History and etymology
Pelvic congestion syndrome was first described in 1857 by Louis Alfred Richet (1816-1891), a French anatomist and surgeon 10.
- 1. Park SJ, Lim JW, Ko YT et-al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol. 2004;182 (3): 683-8. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Umeoka S, Koyama T, Togashi K et-al. Vascular dilatation in the pelvis: identification with CT and MR imaging. Radiographics. 24 (1): 193-208. doi:10.1148/rg.241035061 - Pubmed citation
- 3. Venbrux AC, Chang AH, Kim HS et-al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 2002;13 (2 Pt 1): 171-8. - Pubmed citation
- 4. Haaga JR, Boll D. CT and MRI of the whole body. Mosby. (2009) ISBN:0323053750. Read it at Google Books - Find it at Amazon
- 5. Ignacio EA, Dua R, Sarin S et-al. Pelvic congestion syndrome: diagnosis and treatment. Semin Intervent Radiol. 2008;25 (04): 361-8. doi:10.1055/s-0028-1102998 - Free text at pubmed - Pubmed citation
- 6. Liddle AD, Davies AH. Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 2008;22 (3): 100-4. Pubmed citation
- 7. Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent Radiol. 2013;30 (04): 372-80. doi:10.1055/s-0033-1359731 - Free text at pubmed - Pubmed citation
- 8. Sharma K, Bora MK, Varghese J et-al. Role of trans vaginal ultrasound and Doppler in diagnosis of pelvic congestion syndrome. J Clin Diagn Res. 2014;8 (7): OD05-7. doi:10.7860/JCDR/2014/8106.4570 - Free text at pubmed - Pubmed citation
- 9. Knuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W. Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. (2015) AJR. American journal of roentgenology. 204 (2): 448-58. doi:10.2214/AJR.14.12709 - Pubmed
- 10. Djembi YR, Viard B, Trouilloud P, Trost O, Salomon C. [Alfred-Louis-Dominique Richet (1816-1891): education, anatomy and surgery]. (2015) Morphologie : bulletin de l'Association des anatomistes. 99 (324): 14-7. doi:10.1016/j.morpho.2014.11.002 - Pubmed
- 10. Smith PC. The outcome of treatment for pelvic congestion syndrome. (2012) Phlebology. 27 Suppl 1: 74-7. doi:10.1258/phleb.2011.012s01 - Pubmed
- 11. Asciutto G, Asciutto KC, Mumme A, Geier B. Pelvic venous incompetence: reflux patterns and treatment results. (2009) European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 38 (3): 381-6. doi:10.1016/j.ejvs.2009.05.023 - Pubmed
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