Pelvic congestion syndrome is a medical condition characterized by chronic pain in the pelvis (the lowest part of the torso). It is caused by a pooling of blood in the pelvic veins which become dilated and tortuous. These twisted, enlarged, swollen veins are known as varicose veins and can cause debilitating pain.
Pelvic congestion syndrome (PCS) is one of the most common causes of chronic pelvic pain (chronic pain is defined as pain that lasts for greater than 6 months). PCS frequently occurs in young women of childbearing age, especially women who have had 2-3 pregnancies and childbirths. The reason being the increased size of the womb during pregnancy compresses the ovarian veins and potentially damages the valves in these veins, leading to abnormal backward flow of blood. The resultant build-up of pressure causes varicose veins in the vulva, vagina, inner thighs, buttocks, and sometimes down the legs.
Fortunately, there are effective treatments available for pelvic congestion syndrome. However, PCS is frequently overlooked and under-diagnosed, resulting in inadequate treatment.1 In this article, we describe some of the imaging modalities that are used for the diagnosis of pelvic congestion syndrome.
When is pelvic congestion syndrome suspected?
Pelvic congestion syndrome is suspected when a patient’s chronic pelvic pain cannot be explained by other causes. Meaning, PCS is often a diagnosis of exclusion. The pelvis contains various organs such as the urinary bladder, uterus, cervix, vagina, bowel, and rectum. Pathology in any of these organs can cause pelvic pain. As a result, the list of potential causes of chronic pelvic pain is long and varied, including fibroids, pelvic inflammatory disease, ovarian cysts, bowel diseases, and bladder pathology.
An OB/GYN typically begins evaluation for chronic pelvic pain with a pelvic examination, Pap smear, routine laboratory tests, and imaging.2 Once other pelvic causes of pain have been ruled out, an interventional radiology consultation may be recommended for additional assessment and treatment of pelvic congestion syndrome.
How is pelvic congestion syndrome diagnosed?
Some of the imaging tests that can help diagnose pelvic congestion syndrome include:2
Pelvic ultrasound: This is generally the first imaging study performed in patients who have chronic pelvic pain. It is a non-invasive, non-radiating imaging test that takes about 30 minutes to complete. Visualization of enlarged, twisted pelvic veins and slow and retrograde (reversed) blood flow in the veins are indicative of pelvic congestion syndrome.
Pelvic CT scan: A CT scan of the pelvis can demonstrate varicose veins in the pelvis in greater detail than an ultrasound. However, a CT scan is associated with radiation exposure.
MR venogram: A magnetic resonance venogram is the gold standard in the diagnosis of pelvic congestion syndrome. It is an outpatient, non-invasive, non-radiating imaging study that can demonstrate varicose veins near the uterus, ovaries, and pelvic wall, thus confirming the diagnosis of pelvic congestion syndrome.
Laparoscopy: This is a surgical diagnostic procedure that allows doctors to look directly at organs in the abdomen and pelvis with the help of a camera that is inserted through small incisions. It is a minimally-invasive procedure that may be advised to rule out other causes of chronic pelvic pain and arrive at a diagnosis of PCS by exclusion.
In the United States, 15 out of every 100 women in the 18-50 years age group have chronic pelvic pain.3 The good news is that effective treatments are available for many of the conditions that cause long-standing pain in the pelvis, including pelvic congestion syndrome.
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- Kuligowska E, Deeds L 3rd, Lu K 3rd. Pelvic pain: overlooked and underdiagnosed gynecologic conditions. Radiographics. 2005 Jan-Feb;25(1):3-20. doi: 10.1148/rg.251045511. PMID: 15653583. Available online. Accessed on October 11, 2020. https://pubmed.ncbi.nlm.nih.gov/15653583/
- Ignacio EA, Dua R, Sarin S, et al. Pelvic congestion syndrome: diagnosis and treatment. Semin Intervent Radiol. 2008;25(4):361-368. doi:10.1055/s-0028-1102998. Available online. Accessed on October 11, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036528/
- Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent Radiol. 2013;30(4):372-380. doi:10.1055/s-0033-1359731. Available online. Accessed on October 11, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835435