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Pelvic Congestion Syndrome

Know the Facts

Pelvic congestion syndrome (PCS) is one of the causes of chronic pelvic pain, a condition very common in women that can potentially lead to significant disability. Approximately one third of all women will suffer from chronic pelvic pain at some point during their lifetime. Chronic pain by definition lasts longer than six months and is not related to a woman’s menstrual cycle.

There are many different causes of chronic pelvic pain. This can make diagnosis difficult. Pelvic congestion syndrome (PCS) must be considered if the pain worsens when sitting or standing and is relieved with lying down. Some patients may also experience pain with urination (dysuria) or during/after sexual activity (dyspareunia).

PCS is associated with what is known as ovarian and pelvic vein dilatation. This can result in varicose veins in the pelvis, thighs, buttock regions or vaginal area. A complex medical condition, PCS requires a multidisciplinary team approach to treatment and evaluation.

Symptoms

Symptoms of PCS may include any of the following:

  • Dull, aching or “dragging” pain in the pelvis or lower back, particularly on standing and worse around the time of your menstrual period
  • Irritable bladder that sometimes leads to stress incontinence
  • Irritable bowel (recurrent abdominal pain and diarrhea alternating with periods of constipation)
  • Deep dyspareunia (discomfort during or after sexual intercourse)
  • Vaginal or vulvar varicose veins (bulging veins around the front passage)
  • Varicose veins of the top of the inner thighs or the back of the thighs

Causes

The cause of PCS is unclear. However, the possibility of anatomic or hormonal abnormalities or dysfunction can contribute to the development of PCS. The majority of women who are affected are between the ages of 20 and 45 and with multiple previous pregnancies.

One theory is that hormonal changes and weight gain along with anatomic changes in the pelvic structure during pregnancy can cause an increase of pressure within the ovarian veins. This may weaken the vein wall leading to dilatation. Estrogen also can weaken the vein walls, predisposing women to PCS.

What we do know is that in normal veins, blood flows from the pelvis up toward the heart in the ovarian vein and is prevented from flowing backward by valves within the vein. When the ovarian vein dilates, the valves do not close properly. This results in a backward flow of blood, also known as “reflux.” When this occurs, there is pooling of blood within the pelvis. This, in turn, leads to pelvic varicose veins and clinical symptoms of heaviness and pain.

Risk Factors

Most women with pelvic congestion syndrome are younger than age 45 and in their childbearing years. Certain factors can put a woman at higher risk for the condition, including:

  • Multiple(2 or more) pregnancies
  • Presence of a "tipped" (retroverted) uterus
  • Fullness of the leg veins
  • Polycystic ovaries
  • Hormonal increases or dysfunction

Evaluation

Several diagnostic tests may be useful in evaluating PCS.

Ultrasound: Abdominal and pelvic ultrasound can help evaluate for PCS. With ultrasound we can directly visualize reflux in the ovarian veins and identify dilated pelvic veins. Center for Vein Care is one of only a few centers that can diagnose this condition with ultrasound.

Computed tomography (CT) or magnetic resonance imaging (MRI):
In some situations ultrasound alone may not provide all the necessary information and your physician may want to obtain additional imaging. CT and MRI are used to visualize abnormal veins within the pelvis, look for other abnormalities and evaluate surrounding structures.

Pelvic venography: The most definitive imaging modality for diagnosing PCS, this minimally invasive procedure is performed in the hospital by a vascular specialist. A catheter (tube) enters the venous system from the groin or neck, and x-rays are then used to guide the catheter into the ovarian vein. An iodine-based dye is injected into the vein and images are obtained. Pelvic venography may also be used as a treatment when combined with a nonsurgical, minimally invasive procedure known as pelvic embolization. At your surgeon’s discretion, these procedures may be performed together or at different times.

Treatment Options

Ovarian vein embolization: In this procedure, a catheter (tube) is placed directly into the abnormal ovarian vein and pelvic veins. Sclerosing agents (chemicals that provide irritation or inflammation) are injected into the pelvic varicose veins, and small metal coils or plugs are placed to block flow into the ovarian vein. This prevents the reversal of flow in the abnormal vein, which reduces the pressure within the enlarged pelvic veins. This procedure is typically performed on an outpatient basis, and patients can return to normal activity in a few days. After ovarian vein embolization, approximately 75 percent of patients will report improvement in their symptoms.

> See our interactive blog post about pelvic congestion syndrome on the Department of Surgery website, which offers more information about this condition, plus the experiences of women who have had it.