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Pelvic congestion syndrome

Last revised by Daniel J Bell on 12 Sep 2023

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 ~30% in patients where the presenting complaint is chronic pelvic pain 12.

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 homologue to testicular varicocele. It may be caused by:

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 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.

Pelvic congestion syndrome was first described in 1857 by Louis Alfred Richet (1816-1891), a French anatomist and surgeon 10.

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Cases and figures

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  • Case 12: nutcracker syndrome
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