Pelvic venous insufficiency, commonly referred to as pelvic congestion syndrome (PCS), is an often poorly understood condition that can be hard to diagnose. The condition is caused by pelvic varicose veins or compressed pelvic veins, with chronic pelvic pain being the most common symptom.
Chronic pelvic pain affects about one third of all women at some point in their lives, and about 15 percent of women have pelvic varicose veins, mostly during their childbearing years. PCS symptoms can range from mild pain and discomfort to disabling pain that interferes with work, quality of life and everyday activities.
Despite an increase in awareness of the condition, patients may still not receive a timely diagnosis, leaving some women desperate to find relief. Radiology Associates of North Texas (RADNTX) vascular & interventional radiologist Rob Reeb, Jr., M.D., said that PCS can be a difficult diagnosis for many primary care physicians because:
1. Symptoms are often vague, including significant pain and a feeling of heaviness and aching in the pelvic region
2. Of a lack of awareness of the condition
3. PCS is just one of many possible causes of chronic pelvic pain
The variety of symptoms associated with PCS can lead a physician to doubt that there is truly something serious going on, and it can lead to great frustration on the part of the patient, who is looking for answers to why she is suffering from such pain and discomfort.
“I sincerely understand the doubt on the part of some physicians, because PCS is a vague constellation of symptoms, and many primary care doctors and even some OBGYNs are simply unaware of it or don’t believe in it,” said Dr. Reeb. “But PCS is real and should be included in the differential of chronic pelvic pain. It involves a diagnosis of exclusion, so as physicians, we have to start eliminating possible causes, one by one, to really understand what’s occurring.”
Some patients may also be placed on hormonal therapy before PCS is deemed the appropriate course of action.
“Our interventional radiologists typically do not treat patients for PCS until they have had a full workup by their OBGYN to exclude other potential causes of pain,” emphasized Dr. Reeb. “Our cue to investigate is when chronic symptoms are present and the gynecologist says, ‘I can’t find anything wrong with them.’”
The process of elimination during the patient workup includes some form of imaging, such as a CT scan with contrast, MRI or ultrasound. Dr. Reeb said the radiologist must look for two main signs that a patient may have pelvic vein abnormalities that will respond to treatment.
“We need to see evidence of pelvic varicose veins along with either a dilated left ovarian vein or evidence of left common iliac vein compression, also known as May-Thurner Syndrome,” noted Dr. Reeb. “That’s the tipping point at which we’ll see the patient: when the patient’s primary care doctor and gynecologist have ruled out the more common causes of pelvic pain, and imaging shows pelvic varicose veins.”
After the radiologist sees the patient, reviews all the imaging and is confident of a PCS diagnosis, he or she then talks to the patient about treatment options. Pelvic venography, which is a detailed image of the problematic veins, is used to verify the diagnosis and to plan treatment immediately before the procedure.
If the cause is iliac vein compression – a condition where blood flow through one of these pelvic veins is restricted – the radiologist can place a stent in the affected vein to keep it open and relieve the compression, allowing the blood to flow in a normal fashion.
If the radiologist thinks the cause of pain is ovarian vein insufficiency (pelvic varicose veins), a catheter is placed in the ovarian vein down into the pelvis. A special solution called a sclerosant is injected into the dilated veins so they can be closed off, eliminating the pain and discomfort from the veins that weren’t working properly. The “leaking” ovarian vein is then typically closed with tiny metallic coils.
The patient selection process – deciding which patients should be treated – is extremely important in PCS.
“While some physicians may simply not believe their patient has PCS, others may recommend PCS treatment for anyone with pelvic varicose veins,” observed Dr. Reeb. “But a lot of patients don’t get better because the chronic pain wasn’t related to the varicose veins in the first place, so you have to be careful.”
If a woman has varicose veins in the legs without chronic pelvic pain, the pelvic veins may need to be evaluated with imaging. It could be a sign of an upstream venous blood flow problem in the pelvis.
“For some people with varicose veins in their legs and thighs, their problem could stem from the pelvic region, even though they don’t have PCS,” observed Dr. Reeb. “ That’s when we close off those leaky veins in the pelvic area so that you can get rid of the symptomatic varicose veins in the legs. If your ceiling’s leaking and you patch the ceiling, it’s not going to do any good. You need to fix the leaky roof, not just what’s showing up inside the house.”
Awareness of Pelvic Congestion Syndrome has increased in recent years, and more physicians are referring patients for minimally invasive treatments. Success rates are high – in the 70 to 100 percent range – with successful treatment leading to either a significant reduction in, or elimination of, symptoms.
Treatments are usually done on an outpatient basis, with patients able to return home after a few hours and resume normal activities within a few days.
“It depends on the patient and situation,” noted Dr. Reeb. “There is naturally some inflammation after the procedure and some discomfort for a week or two. Some patients are back to work in two days, some need a week or two.”
“If your physician has ruled out other causes for the pelvic pain you are experiencing and offers no further suggestions, give us a call or find an interventional radiologist with experience treating PCS,” suggested Dr. Reeb.
The Society of Vascular Surgery has endorsed endovascular (interventional radiology) treatment of PCS in published practice guidelines for treatment of chronic venous disease.
What are some clues that patients should look for if they think they might have PCS? Dr. Reeb recommends you talk with your doctor. Look for signs of varicose veins in the legs or lower pelvic region along with chronic pelvic heaviness and pain that is worse toward the end of the day after prolonged sitting or standing. Symptoms may also be worse surrounding periods or after sexual activity.
In addition to PCS, Radiology Associates of North Texas uses minimally invasive techniques to address a range of other conditions.
For more information, visit our Interventional Radiology at radntx.com/vis page or call 817-321-0951.