The ABC of Pelvic Congestion Syndrome
What is Pelvic Congestion Syndrome (Pelvic Congestion Syndrome)?
Pelvic congestion syndrome is a vascular disease that presents itself in the form of chronic pelvic pain lasting for more than three to six months. Since Pelvic Congestion Syndrome is essentially a venous syndrome, it must be the incompetency in the interconnected veins around the pelvic region that cause it. To understand the anatomy underlying Pelvic Congestion syndrome, let’s consider the nervous system in the area around the pelvis. Generally, uterine and internal Iliac veins drain the blood from the uterus and vagina. However, sometimes the fundus of the uterus is drained not into the uterine veins but into the ovarian plexus. The ovarian plexus divides into left and right wherein the former drains into the left renal vein and the right ovarian plexus drains right below the right renal vein. Eventually, these vulvoperineal veins drain into the femoral vein. When the veins in this route are damaged, it may result in inefficient drainage, also known as ‘congestion’, hence giving the syndrome its name.
Increased pressure in the pelvic veins is the primary cause of Pelvic Congestion Syndrome. Consequently, the patient will suffer at the hands of ovarian vein reflux or/and varicose veins. While ovarian reflux happens as a result of faulty valves, varicosities are more commonly seen in multiparous women or in simple words, women who have had more than one full-term pregnancy. The dilatation of veins around the pelvis plays a major role in compromising the venous drainage as it allows pooling of the blood, and increases pressure. Research suggests a 60-fold increase in the capacity of pelvic veins during pregnancy/post-pregnancy to sustain the pregnancy, however this often results in chronic pelvic pain pre and post pregnancy. Moreover, while the woman is pregnant, the veins are compressed by the belly, increasing the pressure and eventually leading to venous incompetency. Now that we have touched on the anatomy of Pelvic Congestion Syndrome, let’s delve into its symptoms, diagnosis and treatment.
Symptoms of Pelvic Congestion Syndrome
It is important to understand that Pelvic Congestion Syndrome can be easily misdiagnosed as there are many reasons for pelvic pain. Only a close eye on the pelvic congestion syndrome symptoms can tell apart Pelvic Congestion Syndrome from other causes of pelvic pain. These include but are not limited to pain in the lower back, thigh and pelvic region which also extends to the postcoital region. The painful sensations may worsen on the onset of menstruation and also during strenuous activity, including standing for a long duration. Once these symptoms are ruled out against other pelvic pathologies, a thorough analysis, diagnosis and treatment will be done by an interventional radiologist or a vascular specialist. To recapitulate, consider consulting your doctor to rule out Pelvic Congestion Syndrome if you have identified all or majority of the following symptoms:
- A prominent pressure felt in the pelvic region
- The pelvic pain has lasted for over 6 months
- Pain extending to lower back; dull but discomforting
- Irritable bladder leading to urinary/stress incontinence
- Anomaly in bowel movements; Alternating between diarrhea and constipation
- Dyspareunia: painful sexual intercourse
How to diagnose Pelvic Congestion Syndrome?
The prerequisite of correct diagnosis for Pelvic Congestion Syndrome is having awareness and working knowledge of the syndrome. Since pelvic pain is a symptom that is cross-cutting in the pathophysiology of several diseases, it is important to first rule out other possibilities. The doctor does not only do confirmatory tests to diagnose Pelvic Congestion Syndrome but also tests that help avoids misdiagnosis. Firstly, a manual examination of the pelvic and abdominal area is performed. This may reveal varicosities in the region and tenderness around the ovaries/uterus area, which will need further attention. Secondly, blood and urine tests may be advised to rule out the possibility of an infection or even pregnancy, which are frequent causes of pelvic pain. A transabdominal ultrasound will also be performed. During this, the patient is lying down in the supine position. However, there is a greater possibility of missing Pelvic Congestion Syndrome in the supine position since there is no distension of the veins and hence no pressure. Therefore, a better approach is to consider examinations in both positions. Furthermore, a transvaginal Doppler Ultrasound gives a comprehensive picture of the venous blood flow in the pelvic region and final confirmation can be drawn from an MRI.
How to Avoid Pelvic Congestion Syndrome – Risk factors
While Pelvic Congestion syndrome can occur in both men and women, the data is strongly bent in the direction of females. Approximately 3 in every 10 women develop Pelvic Congestion Syndrome. In most cases, multiparous women develop congestion in the pelvic after giving birth. The reason for this has already been discussed above. However, even in a non-pregnant state, the pelvic veins are more vulnerable to dilatation. Even more so, female hormones and congenital venous defects are also counted amongst the causes of Pelvic Congestion Syndrome. Finally, obesity is one of the causes of venous insufficiency and pelvic congestion, too. This is why one of the preventive measures for Pelvic Congestion Syndrome includes maintaining healthy weight gain during pregnancy and otherwise.
Pelvic Congestion Syndrome Treatment: Know Your Options
Medical therapy as a part of conservative management can be employed in patients with non-faulty ovarian veins or isolated dilatation in the venous plexus of the pelvic region. Hormone treatment, non-steroidal anti-inflammatory drugs, psychotropic agents combined with psychotherapy all are approaches taken in medical therapy for PCS. Surgical methods to alleviate PCS include vein ligation, hysterectomy and even uterus repositioning. All of these are highly invasive and data suggests a high recurrence rate, too.
Minimally Invasive Endovascular Treatment
With the advancement in medical science, the treatment options for vascular diseases like pelvic congestion syndrome transitioned from being only a few in number and invasive to becoming minimally invasive and alternative approaches. Pelvic Congestion Syndrome treatment through Endovascular embolization is the safest option and has supplanted other surgical routes.. The treatment aims to remedy the underlying cause of Pelvic Congestion Syndrome, which is the venous reflux. The procedure begins with locating and treating the most severely dilated veins or the ones that are distal. This is done via venography in a semi upright position by inserting guiding catheters into the transfemoral or brachial veins with special dyes. This is performed under anesthesia to reach maximum patient compliance. Once the detailed procedure is performed using valsalva maneuver, the Endovascular surgeon detects the varicose veins and vein reflux. The patient is now ready to go under embolization.
Using microcatheter, the distal/dilated veins are chosen for embolization. A well titrated mixture of Cyanoacrylate mixed with lipoidal or a copolymer dissolved in DMSO serves as the embolizing agent while micronized tantalum powder acts as a contrast agent for easy fluoroscopic guidance and visualization. Through this process, reflux veins are blocked up till the distal ovarian vein to include all possible collateral branch points. The embolization procedure requires no coils. Sometimes, complex venous syndrome calls for multiple embolizations. The success of embolization is assessed on the visual analog scale through the pain scores. The patients undergo a strict follow-up after 1 month and then every six months. Eventually yearly follow up for about five years can be expected.
If you reside in Pakistan and suspect that you might have developed Pelvic Congestion Syndrome then it is time to consult Dr. Imtiaz Ahmad, who is a Consultant Endovascular Surgeon and an Interventional Radiologist. He is the pioneer in bringing and conducting embolization in the country since 2017 in the two cities of Pakistan: Karachi and Lahore. So far, he has treated thousands of patients with varying forms of vascular diseases.
Feel free to WhatsApp all your reports to 03302963300 for free assessment by Dr. Imtiaz Ahmad.