Pelvic varices are dialated viens in broad ligaments and ovarian plexus and when is associated with chronic pelvic pain it is called 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.
On this page:
Epidemiology
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 ~30% in patients where the presenting complaint is chronic pelvic pain 12.
Clinical presentation
Patients often have non-cyclical chronic (typically dull and aching) pelvic pain. In certain cases there may be thigh, leg, buttock or vulvar varices. It is often considered a diagnosis of exclusion.
Pathology
Pelvic congestion syndrome is considered the female homologue to testicular varicocele. It may be 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
Radiographic features
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.
Ultrasound
The criteria for diagnose are viens ≥4 mm in diameter and ≤3 cm/s in velocity flow, connecting with arcuate vessels in myometrium
ovarian vein >5-6 mm (positive predictive value of 71-83%)
may show multiple dilated veins in the adnexa with reversed venous flow on colour Doppler, especially after Valsalva manoeuvre
the venous calibres may increase on real time during Valsalva
prominent myometrial veins may also be present 1-8
CT
Contrast enhanced CT typically shows dilated pelvic and ovarian veins. The supine position during scanning may underestimate the size of venous dilatation.
MRI
MR venography
May show dilated veins. Time of flight (TOF) imaging can be performed where contrast is not required.
Signal characteristics
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 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.
History and etymology
Pelvic congestion syndrome was first described in 1857 by Louis Alfred Richet (1816-1891), a French anatomist and surgeon 10.