Pelvic congestion syndrome in Cairns

A dull, dragging ache low in the pelvis that builds through the day and eases when you lie down. Worse before a period, worse after standing, sometimes worse after intercourse. Often present for years, and often investigated several times without a clear answer.

Pelvic congestion syndrome is chronic pelvic pain caused by dilated, refluxing veins in the pelvis. It is under-recognised, partly because the veins involved cannot be seen and partly because pelvic pain has many possible causes that are more commonly considered first.

What it is

The ovarian and internal iliac veins drain blood from the pelvis. As in the legs, these veins contain valves. When those valves fail, blood refluxes back down into the pelvic veins, which dilate and become congested — the same mechanical problem as a varicose vein, in a location where it cannot be seen.

The distended veins produce a persistent, heavy ache. Pressure changes explain the pattern: standing increases it, lying down relieves it, and the venous dilatation that occurs premenstrually makes it worse at that point in the cycle.

Pregnancy is the most common trigger. Blood volume rises substantially, the ovarian veins dilate, and in some women they do not return to their previous calibre afterwards. Symptoms often begin after a first or second pregnancy and are frequently attributed to something else for a long time.

Symptoms

Vulval or upper thigh varicosities, and leg varicose veins that keep recurring at the top of the thigh, are the findings most likely to point toward a pelvic source.

What it is not

Chronic pelvic pain is common and has many causes. Endometriosis, adenomyosis, fibroids, ovarian pathology, pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis and musculoskeletal pelvic floor conditions can all produce similar symptoms, and more than one can coexist.

A gynaecological assessment is a normal and appropriate part of the pathway. Pelvic congestion is generally considered once other causes have been looked for, though it should be considered alongside them rather than only as a last resort — particularly where the postural pattern is clear or visible varicosities are present.

Investigation

Duplex ultrasound is the usual starting point. Scanning the pelvic and ovarian veins, and the veins of the upper thigh and vulva, can demonstrate dilatation and reflux. The scan is performed standing as well as lying, because reflux may be absent when supine. Scans are performed on site at Lake Street by our sonographer, Jovin.

Cross-sectional imaging — CT or MR venography — gives a fuller map of the pelvic veins and identifies compression syndromes such as narrowing of the left renal vein or the left common iliac vein, which can cause or contribute to the picture.

Venography is the definitive study, performed through a small catheter, and is usually done at the same sitting as treatment rather than as a separate diagnostic step.

Treatment

Ovarian vein embolisation is the principal treatment. Access is gained through a vein — usually at the neck or the groin — and a fine catheter is guided to the refluxing ovarian or pelvic vein under x-ray control. Coils, and sometimes a sclerosant agent, are used to close the vein. The blood then drains through the normal pathways.

It is performed under local anaesthetic with sedation, and patients go home the same day.

The published literature reports improvement in pelvic pain in the majority of appropriately selected patients, though results vary between studies and not everyone responds. Selection matters: the more clearly the symptoms fit the venous pattern, and the more clearly reflux is demonstrated on imaging, the more likely embolisation is to help.

Where a compression syndrome is present — the left renal vein compressed between the aorta and the superior mesenteric artery, or the left common iliac vein compressed by the right common iliac artery — treatment may need to address that narrowing rather than, or as well as, the ovarian vein. This changes the plan and is one reason cross-sectional imaging is worth obtaining.

Medical management. Hormonal treatments that suppress ovarian function can reduce symptoms in some women and are sometimes used before or alongside intervention, usually with gynaecological input.

Associated leg veins. Where pelvic reflux is feeding varicose veins in the leg, the pelvic source is generally addressed first. Treating the leg veins while the pelvic reflux remains is a common reason for early recurrence.

Risks and what to expect afterwards

Pelvic ache and cramping in the first few days after embolisation are common, and simple analgesia is usually sufficient. Most people return to normal activity within a few days.

Recognised risks include bruising or bleeding at the puncture site, infection, and reaction to contrast. Coil migration is uncommon. Recurrence of symptoms can occur, and further veins sometimes need treating at a second sitting. Radiation exposure is involved because the procedure is x-ray guided.

Effects on fertility and future pregnancy should be discussed specifically before the procedure. All risks are discussed in full at the consultation.

Common questions

Why has nobody mentioned this before?

Pelvic congestion sits between specialties. The symptoms present to general practice and gynaecology, while the veins are treated by vascular and interventional specialists. It is diagnosed more often now than a decade ago, but it is still frequently reached late.

Do I need a gynaecological review first?

Usually yes, and often in parallel rather than sequentially. Other causes of chronic pelvic pain are more common, and identifying pelvic vein reflux does not exclude them.

Will it definitely fix my pain?

No. Improvement is reported in the majority of well-selected patients, but a proportion see limited benefit, and where more than one cause of pain is present, treating the veins addresses only one of them. This is discussed honestly before any decision.

Is this an operation?

Not in the conventional sense. There is no surgical incision — access is through a needle puncture into a vein. It is performed under local anaesthetic with sedation as a day procedure.

I have varicose veins in my legs that keep coming back. Could this be why?

It is worth investigating, particularly if the veins recur high on the inner or back of the thigh, or if you have veins in the vulval area. A pelvic source is a well-recognised cause of recurrent leg varicosities in women who have had children.

Referral and appointments

GPs and gynaecologists: referrals are welcome for assessment of suspected pelvic vein reflux, particularly where pelvic pain has a clear postural pattern or where vulval, buttock or recurrent upper-thigh varicosities are present.

Patients: phone the rooms on (07) 4254 5006. Suite 9, Level 1, 193 Lake Street, Cairns.