Pelvic Congestion Syndrome - TOG article

Question 1

What % of GOPD referrals are made up of chronic pelvic pain syndrome?

Answer 1

10-40%

Question 2

What is thought to be the prevalence of pelvic congestion syndrome?

Answer 2

3.8-9.9% of women of childbearing age

59% symptomatic

Question 3

What theories exist for the pathophysiology of pelvic congestion syndrome?

Answer 3

Venous engorgement => stretching of the intima of the ovarian vein with distortion of endothelium and smooth muscle => release substance P and neurokinins A and B
Ovarian Varicoceles
Pregnancy and hormonal factors
Nutcracker syndrome

Question 4

Why do ovarian varicoceles form and in what proportion of women are they symptomatic?

Answer 4

Absent venous valves in 15% left ovarian vein and 6% right ovarian vein leading to retrograde flow and primary venous reflux. More frequent in multiparous women.

59% patients symptomatic

Question 5

By how much dow ovarian vein flow increase in pregnancy?

Answer 5

Up to 60 times - causing vein dilatation and ?valve incompetence

Question 6

Why is retrograde flow of the ovarian veins into the internal iliac more common on the left than the right?

Answer 6

Left drains directly to renal vein

Right into IVC at a sharper angle

Question 7

What is ‘Nutcracker syndrome’?

Answer 7

Left renal vein compressed between superior mesenteric artery and aorta
Seen in men with varicocele
In women causes haematuria, abnormal menstruation and left flank pain

Question 8

How do women with pelvic congestion syndrome present?

Answer 8

1. Unilateral or bilateral pain, acute and severe or chronic and dull
2. Exacerbated premenstrually, during pregnancy, fatigue and standing; some have throbbing ache post-coitally
3. Mimic UTI
4. Psych symptoms - depression and anxiety

Question 9

With what other condition is there a 41-56% association?

Answer 9

Polycystic change in the ovaries

Question 10

What are USS findings in pelvic congestion syndrome? (no consensus)

Answer 10

1. Tortuous pelvic veins >6mm in diameter
2. Slow blood flow <3cm/s or reversed caudal flow in left ovarian vein
3. Dilated arcuate veins in myometrium communicating with bilateral pelvic varicose veins
4. Polycystic changes in ovaries (usu not hirsute or oligomenorrhoeic)

Question 11

Which techniques can be used to diagnose pelvic congestion syndrome and which is the definitive modality?

Answer 11

USS
Difficult to diagnose as supine:
- CT
- MRI
Definitive:
- Venography - helpful esp if performing concurrent embolisation

Also:
TRICKS MRV

Laparoscopy - false negs (supine, insufflation into abdomen, compressing veins)

Question 12

What venographic features are suggestive of pelvic congestion syndrome?

Answer 12

1. Ovarian vein >10mm diameter
2. Uterine venous engorgement
3. Congestion of ovarian plexus
4. Filling of pelvic veins across midline +/- filling of the vulvovaginal thigh varicosities

Question 13

What is the medical management of pelvic congestion syndrome?

Answer 13

NSAIDs short term
Oestrogens - COCP
Medroxyprogesterone acetate (MPA)
GnRH agonists (?better at 12/12)
Daflon (micronised purified flavoinoid fraction - venoactive)

Question 14

What is the surgical management of pelvic congestion syndrome?

Answer 14

Ventrosuspension - abandoned
Exptraperitoneal resection of left ovarian vein
Laparoscopic bilateral transperitoneal ligation of ovarian veins
Hysterectomy and BSO with addback - seems to be most effective

Question 15

How effective is endovascular treatment of pelvic congestion syndrome?

Answer 15

Improvement in pai n58-83%
Superior to Hyst+BSO
Unclear whether bilateral or unilateral more effective
Pregnancies following treatment reported

Question 16

What intervention when combined with medical or surgical treatment improves pain outcome?

Answer 16

CBT