Pelvic congestion syndrome

The most significant mechanism for primary dysmenorrhea is the release of prostaglandins in the menstrual fluid and possibly vasopressin-mediated vasoconstriction.5,17 Causes of secondary dysmenorrhea may include cervical stenosis, endometriosis, pelvic infections, pelvic congestion syndrome, uterine or cervical polyps, and uterine fibroids.20... 

Paul Barney, M.D., a physician from Layton, Utah, combines the use of orthodox medicine with herbs, nutrition, and acupuncture. At the 1998 International Saw Palmetto Symposium, he spoke of using Serenoa for pelvic congestion syndrome. This con-... 

Maleux G, Stockx L, Wihns G, Marchal G (2000) Ovarian vein embolization for the treatment of pelvic congestion syndrome long-term technical and clinical results. J Vase Intervent Radiol 11 859-864... 

Pelvic congestion is a complex subject. When considering the pathophysiology, two components must be considered (Fig. 11.1) gonadal vein reflux, which is the commonest cause of pelvic varicosities, and the pelvic varicosities themselves, whidi are felt to be the principle cause of pain in pelvic congestion syndrome. Each maybe seen without the other, and both can be present in asymptomatic patients. 

The association between varicose veins in the pelvis and pelvic pain in women has been known since the description of tubo-ovarian varicocele by Richet in 1857 [1]. However, it was not until 1976 that the phrase pelvic congestion syndrome was coined by Hobbs [2] to describe a syndrome of chronic pelvic pain and heaviness due to pelvic varicosities. The pelvic varicosities are almost always secondary to reversed flow in the ovarian vein, in essence a female... 

Some authors suggest that renal vein obstruction is a common etiology of ovarian vein reflux. This does not reflect the author s experience. A Belgian study of 48 patients with pelvic congestion syndrome found that 83% had extrinsic compression of the left renal vein between the aorta and the superior mesenteric artery resulting in the nutcracker phenom-... 

Fig. 11.1. Pelvic congestion syndrome. Selective injection of the left ovarian vein reveals retrograde flow in a dilated left ovarian vein and results in opaciflcation of an extensive network of pelvic varicosities...

Ovarian cysts may be seen in women with pelvic congestion syndrome ranging from a few cysts to polycystic ovary syndrome produced by estrogen overstimulation. 

Therapeutic modalities which have been applied to pelvic congestion syndrome include psychotherapy, physiotherapy, analgesia alone, pharmacologic ovarian suppression, surgery, and embolization. Critical comparison of treatment outcomes between different therapies is difficult, if not impossible. Not only are a wide variety of therapeutic endpoints described, but diagnostic criteria are different (or not described at all) in virtually every study. 

Multiple surgical treatments have been performed for pelvic congestion syndrome. Bilateral oophorectomy and hysterectomy with subsequent hormone replacement has been reported with symptom improvement in 66% of women [29]. Surgical ligation of the left ovarian vein has been described resulting in improvement in 73% of women [30], and left nephrectomy (at time of renal donation) with an 77.9% symptom improvement [31]. In the latter study of 273 female renal donors, 27 had evidence of left ovarian venous reflux, of whom 22 completed a questionnaire about symptoms. Of these, 13 reported pelvic pain and ten had reduced or absent symptoms after left nephrectomy. 

Using enbucrylate and coils Carpasso et al. (1997) reported the results of embolization in 19 women with pelvic congestion syndrome [36]. A total of 13 patients required unilateral embolization and six bilateral. Five patients developed recurrence treated successfully by embolization. Initial technical success rate was 96.7%, and there were no complications. At mean follow-up of 15.4 months, 73.7% of patients reported improved symptoms with pain relief rated as complete in 57.9%. The authors noted that the eight patients who had only partial or no relief suffered from dyspareunia and felt this was a negative prognostic factor. (By comparison, most studies report that dyspareunia is a symptom that does respond to treatment). 

CoRDTS et al. (1998) described ovarian vein embolization in nine women with symptoms of pelvic congestion syndrome using coils and absorbable gelatin sponge [37]. Embolization of both ovarian veins was performed in four women, of the left ovarian vein alone in four patients, and of a left obturator vein that communicated with vulvar varices in one patient. The authors reported that eight of the nine women (88.9%) had more than 80% immediate relief but that two women had a mild to moderate return of the symptoms at 6 and 22 months. Improvement in symptom relief varied from 40% to 100% at a mean time of 13.4 months. 

Desimpelaere JH, Seynaeve PC,et al. (1999) Pelvic congestion syndrome demonstration and diagnosis by helical CT. Abdom Imaging 24 100-102... 

Gargiulo T, Mais V, et al. (2003) Bilateral laparoscopic transperitoneal hgation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Lapar-osc 10 501-504... 

Venbrux AC, Chang AH, et al. (2002) Pelvic congestion syndrome (pelvic venous incompetence) impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vase Interv Radiol 13 171-178... 

Cordts PR, Eclavea A, et al. (1998) Pelvic congestion syndrome early clinical results after transcatheter ovarian vein embolization. J Vase Surg 28 862-868... 

Machan LS and Martin ML (2000) Ovarian vein embolization for pelvic congestion syndrome. Semin Intervent Radiol 17 277-284... 

Park SJ, Lim JW, Ko YT et al (2004) Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal... 

Fig. 17.10a-c. Pelvic congestion syndrome. Transaxial CT at the level of the cervix uteri (a) and coronal scans in the pelvis and retroperitoneum (b, c). Multiple dilated tortuous pelvic vascular structures are demonstrated within the parametria and pelvic sidewalls (a). The coronal images demonstrate engulf-ment of the uterus (U) by these vascular structures (b, c). Dilatation of both ovarian veins (arrows), which display a diameter of more than 8 mm, is shown in c. U, uterine corpus, C, cervix... 

Several treatment options for pelvic congestion syndrome, including laparoscopic transperitoneal ligation of ovarian veins are currently under investigation. Percutaneous coil embolization of the gonadal vein seems to be a safe technique that relieves pelvic pain in many patients with pelvic congestion syndrome [27]. 

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