Symptoms of pelvic venous congestion syndrome.
- Pain. Women with pelvic venous congestion syndrome often develop pelvic pain after
pregnancy. The pain usually gets worse with each pregnancy.
The pain is usually dull, but it can also be sharp or throbbing. It gets worse at the end of the day (after
sitting or standing for long periods of time)
and goes away when lying down. The pain also gets worse during or after sexual intercourse. It is often
accompanied by lower back pain, leg pain, and abnormal
vaginal bleeding. The pain usually occurs on one side only.
- Pain on deep palpation of the ovaries
- Dyspareunia.
- Presence of varicose veins of the buttocks and/or lower extremities.
- Headache.
- Gastrointestinal pain/discomfort.
- Bowel and bladder dysfunction.
- Fatigue.
- Insomnia.
- Feeling of heaviness in the lower abdomen or perineal area.
- Lower back pain increases when standing upright.
- Depression.
- Discharge from the vagina.
- Dysmenorrhea.
- Edema of the vulva.
- Lumbosacral neuropathy.
- Rectal discomfort.
Diagnosis of pelvic venous congestion syndrome.
A diagnosis of pelvic venous congestion syndrome is suspected when a woman presents with
pelvic pain, but a pelvic exam does not reveal the presence of inflammation or other abnormality. For a
physician to diagnose pelvic venous congestion syndrome, pain must be present for more than 6 months and the
ovaries must be painful on examination.
Ultrasound to detect pelvic varices may help confirm the diagnosis or pelvic venous congestion syndrome.
However, other imaging studies may be needed to confirm the diagnosis. These studies may include venography
(x-ray examination of the veins performed after injection of a radiopaque contrast agent into the veins of
the inguinal region), computed tomography (CT), magnetic resonance imaging (MRI), or magnetic resonance
venography.
The diagnostic criteria for the diagnosis of pelvic venous congestion syndrome on ultrasound are:
- tortuous pelvic veins > 6 mm in diameter
- Slow blood flow < 3 cm/s or reverse caudal blood flow
- Dilated arcuate veins in the myometrium communicating between bilateral pelvic varices
- Polycystic changes in the ovaries
Diagnostic criteria for the diagnosis of PVCS on ultrasound are:
• Tortuous pelvic veins diameter > 6 mm
• Slow blood flow < 3 cm/sec or reversed caudal flow
• Dilated arcuate veins in the myometrium communicating between bilateral pelvic varicose veins
• Polycystic changes in the ovaries
The ultrasound exploration allows the positive diagnosis of pelvic venous involvement and the classification by pathophysiological types, which is a key step before any treatment. The echo Doppler is also essential for the diagnosis of superficial points of pelvic venous leaks supplying lower-limb varicose veins. In most symptomatic patients, ultrasound exploration provides sufficient arguments to evaluate the relevance of the pelvic-level venous treatment. It leads to additional imaging techniques, if necessary, or directly to a hyperselective descending pelvic venography. This last investigation provides an accurate mapping of varicose veins and pelvic venous reflux.
Villalba L. Our Protocol for Transabdominal Pelvic Vein Duplex Ultrasound. 2018.
A summary of South Coast Vascular Laboratory's protocol for pelvic vein duplex ultrasonography, including equipment, patient positioning, ultrasound settings, and technique.
Diagnosis and treatment of pelvic congestion syndrome: UIP consensus document (2019)
Despite that transvaginal ultrasound more correctly show enlargement and congestion of pelvic veins, transabdomi¬nal ultrasound have a great diagnostic value because of direct visualization of left ovarian vein. An ovarian vein diameter of 6 mm on transabdominal ultrasonography has been reported to have a 96% positive-predictive value for pelvic varices.
The transvaginal approach is considered to be the exami¬nation of choice since it offers better visualization of the pelvic venous plexus compared to transabdominal ultra¬sound, and is not hampered by patient habitués or undis¬placeable bowel gas.41 Another advantage of ultrasound examination is the possibility to perform it on standing position and also evaluation of venous filling during Val¬salva maneuver.
«More recently, authors (20,32–34) suggested that transvaginal duplex US could replace venography as the criterion standard screening imaging method»
20. Holdstock JM, Dos Santos SJ, Harrison CC, Price BA, Whiteley MS. Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux. Phlebology 2015;30(2):133–139.
32. Hansrani V, Dhorat Z, McCollum CN. Diagnosing of pelvic vein incompetence using minimally invasive ultrasound techniques. Vascular 2017;25(3):253–259.
33. Whiteley MS, Dos Santos SJ, Harrison CC, Holdstock JM, Lopez AJ. Transvaginal duplex ultrasonography appears to be the gold standard investigation for the haemodynamic evaluation of pelvic venous reflux in the ovarian and internal iliac veins in women. Phlebology 2015;30(10):706–713.
34. Labropoulos N, Jasinski PT, Adrahtas D, Gasparis AP, Meissner MH. A standardized ultrasound approach to pelvic congestion syndrome. Phlebology 2017;32(9):608–619.
The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography (VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative. Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An observational prospective study including 67 patients was carried out.
Ultrasound TAU and TVU should be combined with colour Doppler imaging (CDI) and Doppler spectral analysis (Kuligowska et al. 2005; Stones et al. 1990; Hodgson et al. 1991; Lemasle and Greiner 2017).
The diagnosis of pelvic congestion syndrome (PCS) remains a challenge given the lack of universally accepted criteria. Although venography (VG) is the current gold standard for the diagnosis of PCS, non-invasive techniques like transvaginal ultrasonography (TVU) appear to be a valid alternative. The aim of this study was to design a predictive model for the venographic diagnostic of PCS using the parameters identified by TVU in patients with clinical suspicion of PCS, in order to individually assess the need to perform an invasive diagnostic and therapeutic technique such as VG.