Pelvic congestion syndrome

Overview

Pelvic congestion syndrome (PCS) is a chronic medical condition characterized by persistent pelvic pain in women, caused by varicose veins in the pelvis. These dilated, twisted veins—typically involving the ovarian and pelvic veins—lead to venous insufficiency and blood pooling, resulting in a dull, aching discomfort that worsens with prolonged standing, during or after sexual intercourse, or before menstruation. PCS is considered one of the potential causes of chronic pelvic pain, particularly in premenopausal women who have had multiple pregnancies. Although often underdiagnosed or misattributed to other gynecological conditions, PCS can significantly affect a woman’s quality of life if left untreated.

Causes

Pelvic congestion syndrome is caused by venous insufficiency in the pelvic veins, similar to varicose veins in the legs. The primary causes and contributing factors include:

• Valve dysfunction in the pelvic veins: When valves in the ovarian or internal iliac veins fail, blood flows backward and pools, leading to vein dilation

• Hormonal influences: Estrogen can weaken vein walls and valves, contributing to varicosity

• Pregnancy-related changes: Increased blood volume, hormonal changes, and uterine enlargement during pregnancy can stretch and damage pelvic veins

• Multiple pregnancies: Repeated pregnancies are associated with a higher risk due to cumulative strain on pelvic vasculature

• Compression of pelvic veins: Conditions like Nutcracker syndrome or May-Thurner syndrome can obstruct venous outflow, contributing to PCS

Although rare, PCS may also be associated with congenital abnormalities in the venous system.

Symptoms

The symptoms of pelvic congestion syndrome are often chronic and may vary in severity. Common signs and symptoms include:

• Chronic pelvic pain: A dull, aching pain lasting more than six months, usually located on one or both sides of the lower abdomen

• Worsening of pain: Increased discomfort with prolonged standing, sitting, or physical exertion

• Dyspareunia: Pain during or after sexual intercourse

• Menstrual-related discomfort: Pain may intensify before the start of menstruation

• Urinary symptoms: Increased frequency, urgency, or bladder pressure

• Visible varicose veins: In the vulva, buttocks, or upper thighs

• Lower back pain: Especially in the sacral region

These symptoms often mimic those of other gynecological or gastrointestinal conditions, making diagnosis challenging.

Diagnosis

Diagnosing pelvic congestion syndrome involves a combination of clinical evaluation, imaging studies, and exclusion of other causes of pelvic pain. The diagnostic process may include:

• Detailed medical history: Focused on pain duration, relation to posture, menstrual cycle, and sexual activity

• Pelvic examination: May reveal tenderness over the adnexa or visible varicosities in the vulvar region

• Transvaginal ultrasound: Can detect dilated pelvic veins and rule out other pelvic pathologies

• Pelvic Doppler ultrasound: Evaluates blood flow and identifies reflux in the pelvic veins

• CT or MRI scan: Provides detailed imaging of pelvic structures and venous anatomy

• Venography (gold standard): A specialized X-ray using contrast dye to visualize and measure the extent of pelvic vein reflux

Because PCS can mimic conditions like endometriosis, fibroids, or irritable bowel syndrome, a multidisciplinary approach is often necessary to confirm the diagnosis.

Treatment

Treatment of pelvic congestion syndrome depends on the severity of symptoms and the impact on quality of life. Options range from conservative management to minimally invasive procedures:

Conservative Management:

• Medications: Hormonal therapies (e.g., medroxyprogesterone, GnRH analogs) can suppress ovarian function and reduce pelvic vein dilation

• Pain management: NSAIDs to control pelvic discomfort

• Lifestyle modifications: Avoiding prolonged standing, wearing compression garments, and engaging in regular exercise

Minimally Invasive Interventions:

• Pelvic vein embolization: A catheter-based procedure in which coils or sclerosants are used to block abnormal pelvic veins and redirect blood flow; it is the preferred treatment for most cases

• Sclerotherapy: Injection of a chemical solution to collapse the problematic veins

Surgical Treatment (rare):

• Ligation or resection of pelvic veins: In cases where embolization fails or is not feasible

• Hysterectomy with oophorectomy: Considered only in severe, refractory cases when childbearing is complete and other treatments have failed

Prognosis

The prognosis for pelvic congestion syndrome is generally favorable with appropriate treatment. Many women experience significant relief from symptoms following pelvic vein embolization, with success rates exceeding 80%. Early recognition and intervention can prevent chronic pain and improve overall quality of life. However, PCS can recur, particularly if underlying venous insufficiency is not fully corrected. Long-term follow-up and patient education are important to manage expectations and detect any recurrence of symptoms. With growing awareness and improved diagnostic techniques, outcomes for women with PCS continue to improve.