How clinicians confirm pelvic congestion syndrome when symptoms overlap with other pelvic pain disorders.
PCS Diagnosis: Clinical and Imaging Guide
Use this overview to recognise red flags, choose the right imaging pathway, and understand the evidence that supports a PCS diagnosis.
Return to PCS OverviewWhen to Suspect PCS
PCS is often suspected when pelvic pain persists despite a normal pelvic exam. Key symptom patterns include:
Frequent clinical clues:
- Pelvic pain beginning after pregnancy and worsening with each subsequent pregnancy.
- Dull, aching pain that can flare to sharp or throbbing sensations, often worsening later in the day or after prolonged standing or sitting and easing when lying down.
- Pain that intensifies during or after sexual intercourse.
- Symptoms frequently present on one side of the pelvis.
- Pain reproduced on deep palpation of the ovaries during examination.
- Visible varicose veins affecting the vulva, buttocks, or lower extremities.
- Associated lumbosacral neuropathy or radiating lower back pain, especially when standing upright.
- Systemic complaints such as fatigue, insomnia, headaches, depression, or bowel and bladder dysfunction.
- Gastrointestinal discomfort, rectal pressure, and abdominal bloating.
- Dysmenorrhea, abnormal vaginal discharge or bleeding, and vulvar edema.
Ultrasound First-Line
Transabdominal ultrasound (TAU) helps visualise pelvic varices, while transvaginal ultrasound (TVU) provides higher-resolution views of the pelvic venous plexus.
Practical tips from clinical protocols:
- Combine TAU and TVU with colour Doppler imaging and spectral analysis to characterise reflux patterns (Kuligowska 2005; Stones 1990; Hodgson 1991; Lemasle 2017).
- Use patient positioning (standing or Valsalva manoeuvre) to provoke venous filling when assessing reflux.
- Identify superficial pelvic leak points that may feed lower-limb varicose veins before planning treatment.
- An ovarian vein diameter ≥ 6 mm on TAU carries a reported 96% positive predictive value for pelvic varices.
Villalba (2018) and South Coast Vascular protocols outline recommended ultrasound equipment, settings, and step-by-step approaches.
Ultrasound Diagnostic Criteria
Multiple studies converge on a core set of ultrasound findings that support a PCS diagnosis:
- Tortuous pelvic veins measuring greater than 6 mm in diameter.
- Slow venous flow under 3 cm/sec or reversed caudal flow.
- Dilated arcuate veins in the myometrium communicating between bilateral pelvic varices.
- Polycystic changes in the ovaries associated with venous stasis.
Key references: Park et al. (AJR 2004); Lemasle & Greiner (Phlebolymphology 2017).
Hyperselective descending pelvic venography remains the gold standard for mapping reflux and planning embolisation when intervention is considered.
CT or MR imaging (including MR venography) helps characterise venous dilation, rule out compressive syndromes, and support multidisciplinary decisions.
Recent TVU predictive models (Valero 2022; Garcia-Jimenez 2023) assist in triaging who truly needs invasive venography.
Evidence Base
International guidelines and consensus documents recognise ultrasound—especially TVU—as a reliable screening tool, with venography reserved for definitive confirmation and treatment planning.
- UIP Consensus (2019): Endorses combined TAU/TVU protocols and highlights the diagnostic value of standing and Valsalva assessments.
- Bookwalter (2019): Notes emerging agreement that transvaginal duplex ultrasound can replace venography as the first-line haemodynamic study.
- Kashef (2023): Recommends pairing ultrasound modalities with colour Doppler for comprehensive venous assessment.
- Holdstock et al. (2015) and Whiteley et al. (2015): Link haemorrhoids and pelvic reflux, reinforcing the need to evaluate pelvic veins in complex varicose presentations.
Together, these findings support a progressive diagnostic pathway: recognise symptom clusters, document reflux on ultrasound, then escalate to venography or advanced imaging when intervention is planned.