Prostatic artery embolization
October 13, 2014
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Pelvic congestion syndrome (PCS) is a poorly understood and often overlooked etiology of chronic pelvic pain. Millions of women worldwide may develop chronic pelvic pain at some time in their life, and the occurrence may be as high as 39.1%.

Chronic pelvic pain can be debilitating and accounts for 10% to 15% of all gynecologic visits. Managing this complex condition can be a challenge for the primary-care provider. When clinical and ultrasound examinations are normal, further diagnostic imaging can helpful to obtain the diagnosis. Once identified, PCS can be treated successfully with embolization therapy.

PCS is associated with dilated pelvic varices with reduced venous clearance, most often as a result of retrograde flow in an incompetent ovarian vein. The condition is seen more often in multiparous premenopausal women. A relationship between PCS and endogenous estrogen levels is suggested, as estrogen is known to weaken the vein walls.

It is estimated that one-third of all women will experience chronic pelvic pain in their lifetime. Recent advancements show the pain may be due to hard-to-detect varicose veins in the pelvis, known as pelvic congestion syndrome.

The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don’t close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.

The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing.

Many women with pelvic congestion syndrome, spend many years trying to get an answer to why they have this chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.

If you have pelvic pain that worsens throughout the day when standing, you may want to seek a second opinion with an interventional radiologist, who can work with your gynecologist. You can ask for a referral from your doctor, call the radiology department of any hospital and ask for interventional radiology or visit the doctor finder link at the top of this page to locate a doctor near you.

Prevalence

  • Women with pelvic congestion syndrome are typically less than 45 years old and in their child-bearing years.
  • Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
  • Chronic pelvic pain accounts for 15 percent of outpatient gynecologic visits.
  • Studies show 30 percent of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15 percent have PCS along with another pelvic pathology.

Risk Factors

  • Two or more pregnancies and hormonal increases
  • Fullness of leg veins
  • Polycystic ovaries
  • Hormonal dysfunction

Symptoms

The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:

  • Following intercourse
  • Menstrual periods
  • When tired or when standing (worse at end of day)
  • Pregnancy

Other symptoms include:

  • Irritable bladder
  • Abnormal menstrual bleeding
  • Vaginal discharge
  • Varicose veins on vulva, buttocks or thigh.

Once other abnormalities or inflammation has been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods. An interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use the following imaging techniques to confirm pelvic varicose veins that could be causing chronic pain.

Pelvic venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, interventional radiologists examine patients on an incline, because the veins decrease in size when a woman is lying flat.

MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.

Pelvic ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done is an very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.

Transvaginal ultrasound: This technique is used to see better inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems.

Transvaginal ultrasound is helpful in identifying ovarian cysts or uterine leiomyomas. If the ultrasound results are inconclusive, an MRI of the pelvis (with and without contrast) is warranted. MRI is helpful with demonstration of the ovarian vein (Figure 1) and varicosities.

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Figure 1

Dynamic imaging can confirm the active reflux from the ovarian vein. Bear in mind that the MRI is done in the supine position, which can alter the appearance of the varicosities in the pelvis. Whenever possible, the MRI should be scheduled for later in the day or early evening to coincide with a woman’s increased perception of symptoms.

After the diagnosis of PCS has been identified, medical treatment with non-steroidal anti-inflammatory drugs may help relieve the patient’s pain for the short term. Analgesia is a good first-line option, but if symptoms do not improve, a referral to an interventional radiologist should be made.

An interventional radiologist specializes in minimally invasive treatments using imaging for guidance. This clinician performs a thorough history and physical and reviews the imaging with the patient before scheduling her for pelvic venography.

Pelvic venography an outpatient procedure and remains the gold standard for diagnosis of PCS. During venography, contrast dye is injected into the veins of the pelvis to make them visible via fluoroscopy, using the jugular vein for access. Performing the procedure with the patient placed on an incline will improve the accuracy of the diagnosis.

If this is not an option, a Valsalva maneuver is required and is often best achieved by having the patient blow into the tubing of a sphygmomanometer and hold the mercury at approximately 20 mm. If no reflux is present, a diagnosis of PCS is highly unlikely. If pelvic and/or ovarian varicosities are present (Figure 2), embolization of the offending abnormal vein can be performed.

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Figure 2

In this procedure, the interventional radiologist inserts a small guidewire and catheter into the faulty vein and embolizes it with coils, plugs, or sclerosant (Figure 3).

After treatment, women are discharged home the same day and able to return to regular activity the next day. Some patients may experience some mild cramping for 24 to 48 hours, which is managed well with ibuprofen.

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Figure 3

Efficacy

In addition to being less expensive to surgery and much less invasive, embolization offers a safe, effective, minimally invasive treatment option that restores patients to normal. The procedure is very commonly successful in blocking the abnormal blood flow. It is successfully performed in 95-100 percent of cases. A large percentage of women have improvement in their symptoms, between 85-95 percent of women are improved after the procedure. Although women are usually improved, the veins are never normal and in some cases other pelvic veins are also affected which may require further treatment.

Embolization is successful in 98% to 100% of all PCS cases, with recurrence rates of less than 8%. Symptom improvement has been documented in 70% to 85% of women studied and can be expected within two to four weeks post procedure. Long-term follow-up data are minimal, however a study revealed that 83% of patients continued to remain symptom-free four years post treatment.

Because it can negatively affect the quality of life and personal relationships of women and result in physical and psychological suffering, chronic pelvic pain is a significant health problem for many women. Patients with chronic pelvic pain report a high incidence of anxiety, depression and physical worries.

Embolization offers a safe, effective and minimally invasive treatment option that can improve or resolve symptoms in women with chronic pelvic pain caused by PCS.