Pelvic Congestion Syndrome

Pelvic congestion syndrome is a term used to describe a set of symptoms related to the presence of multiple varicose veins in the pelvis. It was first described by Richet in 1857 as ovarian varicocele. Abnormal dilatation of the ovarian veins could be seen in 9.9% of the general population but only 59% of them might develop pelvic congestion syndrome [Belenky et al, 2002]. It could be seen in all age groups within the reproductive years but is more common between the ages of 25-35 years. Alleged symptoms are variable and bear little relationship to the apparent severity of the condition. Symptoms are attributed to ischaemia of the tissues and blood vessels themselves subsequent to slow blood drainage and stasis especially following increased intra-abdominal pressure. It is worse while sitting, standing and lifting and could be relieved by lying down. It could as well present with postcoital pain which could last for few hours or days. It is mostly felt on one side but could be bilateral. It could be associated with varicose veins in the vulva, vagina and upper thighs. The spectrum of symptoms includes:

• Dull pelvic ache with intermittent episodes of sharp pains.
• Aching or burning sensation overlying the area of the varicosities.
• Painful menstruation and low backache.
• Pain during or after sexual intercourse.
• Increased vaginal discharge with repeated negative microscopy and microbial culture.
• Dysfunctional uterine bleeding

Normally the mean calibre of the ovarian vessels is 3.5-4.2 mm, with the left one usually wider than the right one. They could reach up to 6.8 mm in cases with incompetent valves [Park et al, 2004]. Various theories have been put forward to explain why these vessels tend to dilate. The most probable ones are absent or incompetent venous valves and abnormality of the collagen fraction in the blood vessel wall. It was shown that normally 13-15% of women lack valves in the left ovarian vein in comparison to 6% on the right side. On the other hand, excessive local production of oestrogens could lead to dilatation and stasis of blood in the pelvic veins leading to pelvic pain in women with abnormal ovarian function [Kroon and Reginald, 2005]. Certain women are more likely to show these vascular changes but are not necessarily symptomatic including:

• Ultrasonically diagnosed polycystic ovaries were seen in 40.6% of patients with pelvic congestion syndrome compared to 11.4% in a control group [Park et al, 2004].
• Multriparous women
• Women with retroverted uterus

Furthermore, women with pelvic congestion syndrome were described to have larger uterine cross sectional area and thicker endometrium than other women. Abdominal pressure at the 'ovarian points' during clinical examination could reproduce the patient's pain.

Though venography is generally considered to be the most definitive radiological investigation for patients with suspected pelvic congestion syndrome [Cheong and Stones, 2005], it is not frequently used for that purpose. It could show reduced drainage and clearance of the contrast medium from the dilated ovarian and uterine veins. However, with transvaginal scan examination multiple circular or elongated sonolucent areas 3-5 mm or more in diameter could be seen on one or both sides of the cervix. They become more prominent with increased intra-abdominal pressure. With 3D technology a better visual picture could be obtained by scanning across the upper cervix and lower uterine cavity.

 

The two ultrasound images shown above demonstrate increased vascular marks in the left broad ligament compared to the right side in two patients examined with 2D colour Doppler and 3D power Doppler respectively.

Pelvic congestion may also be seen during laparoscopic examination, especially in the broad and infundibulopelvic ligaments. However, previous reports showed no correlation between venography and the findings during laparoscopy. This may be due to the modulating effect of the head down position and increased intra abdominal pressure sustained during laparoscopy.

The two laparoscopy pictures shown below depict pelvic congestion of the broad ligaments during laparoscopy. Congestion on both sides was very evident despite the patient being in 30º Trendelenburg position

 

Management of pelvic congestion syndrome

Despite the long duration of time since this diagnosis was first described, no specific treatment has yet been agreed upon. This could be a reflection of the general hesitancy by gynaecologists to accept even the existence of the pathology itself. However, both medical and surgical means have been described with variable results.

Medical treatment

Medroxyprogesterone acetate (MPA) in a daily dose of 30 mg for 6 months has been shown to cause temporary symptomatic relief as well as reducing the size of the dilated vessels themselves. One study reported such an effect in 77% of the patients so treated. However, suppressing ovulation with the oral contraceptive pills failed to give similar symptomatic relief suggesting a direct antioestrogenic effect by MPA on the blood vessels. Unfortunately, this was a short-term remedy which lasted only while using the drug [Kroon and Reginald, 2005]. Dihydroergotamine has also been used but there is no enough general experience with it as for medroxyprogesterone acetate. Furthermore, downregulation with monthly injections of a GnRH analogue provided symptomatic relief, improved sexual function and reduced anxiety and depressive states [Kroon and Reginald, 2005]. On the other hand, Simsek et al in 2007 showed that 3 months use of Daflon, which is a venomimetic agent capable of regulating the circulatory venous tone, resulted in significant reduction in the frequency and severity of symptoms. They concluded that pharmacological augmentation of venous tone could improve the pelvic circulation and relieve patients’ symptoms.

 Surgical treatment

Different surgical techniques have been used in the management of pelvic congestion syndrome including ovarian vein ligation, hysterectomy with or without removing the ovaries and tubes. Ovarian veins ligation was successful in giving symptomatic relief in only 50% of the cases whereas hysterectomy was not successful unless combined with bilateral salpingo-oophorectomy. Another surgical technique which gave some favourable response is correction of uterine retroversion by shortening of the uterosacral ligaments. Catheter embolisation of the ovarian veins is proving at least as effective as surgery for relieving patients symptoms. Maleux et al [2000] reported 58.5% total relief of symptoms where as Kim et al [2003] reported 83% clinical improvements at long term follow up. The last figure is almost identical to the one reported by Kwon et al in 2007 after ovarian vein embolisation using coils. This dramatic improvement in the reported results over the years might indicate improvement in the technical abilities of the intervention radiologists with time.

The 6 photographs shown above demonstrate left pelvic sidewall varicose veins dissected and clipped. Only few of the clips are shown in these photographs. Varicosity can be seen lateral to the left uterosacral ligament, pelvic sidewall, the left broad ligament and lateral to the infundibulopelvic ligament. The patient had chronic pelvic pain with no other demonstrable cause. Ultrasound scan examination revealed left side pelvic congestion which did not respond completely to high doses of medroxyprogesterone acetate for a period of 6 months. Her symptoms, mainly deep dyspareunia and postcoital pain, subsided for one year after surgery. The patient was lost to follow up afterwards. Despite the good success with this case, it does not mean that such a procedure will be equally successful in all other similar cases.