Pelvic congestion syndrome
Chronic pelvic pain caused by varicose veins of the ovarian and uterine veins. It is more common in women of childbearing age who have had children and remains under-diagnosed.
Why does it happen?
- Reflux: the valves of the ovarian or internal iliac veins stop working, often after pregnancy, because of the large increase in blood volume and the dilatation of the veins.
- Obstruction: compression of the left renal vein (Nutcracker) or the left iliac vein (May-Thurner) hinders drainage and forces blood to find alternative routes through the pelvis.
- A combination of both, which is common.
These pelvic varicose veins can connect with the veins of the vulva, perineum and legs and cause atypical varicose veins in those areas.
Symptoms
- Pelvic pain or heaviness lasting more than six months, which worsens when standing, at the end of the day and before a period.
- Pain during or after sexual intercourse.
- Painful or heavy periods.
- Pain in the groin, the inner thighs or the lower back.
- Vulval, perineal or leg varicose veins with an unusual distribution, often after a pregnancy.
- In cases of renal vein compression, blood in the urine, sometimes only visible on testing.
Diagnosis
- A focused clinical history and exclusion of other causes together with gynaecology.
- Abdominal and transvaginal duplex ultrasound: shows the pelvic varicose veins, their size and the reflux.
- MRI or CT to look for venous compressions.
- Venography, ideally with IVUS, to confirm the diagnosis and plan treatment.
Treatment
EmbolisationIf the cause is reflux in the ovarian or pelvic veins, they are closed from the inside with coils, sclerosant foam or plugs, through a catheter inserted into a vein.
Venous stentIf the cause is a compression, a stent is placed to restore flow and decongest the pelvis.
A systematic review of 21 case series and one trial, including 1,308 women, found significant pain relief in around 75% after embolisation, which was generally maintained or increased over time. Complications were uncommon (coil migration in fewer than 2%) and no negative effects on menstruation or fertility were observed, although the authors note that the quality of the evidence is low and more trials are needed.
The procedure is performed under local anaesthesia and sedation, without incisions, and recovery is quick. Transient pelvic discomfort in the first few days is common.
At Clínica Rotger we treat this condition routinely, and I direct the training workshops on the diagnosis and treatment of abdominal and pelvic venous disease for other specialists.
Varicose veins of pelvic origin in the vulva and legs
Dilated pelvic veins can connect with those of the vulva, perineum, inner or back of the thigh and buttock through so-called pelvic escape points. These varicose veins often appear or worsen after a pregnancy and explain many leg varicose veins that recur after surgery.
If their pelvic origin is not identified, treatment of the legs may fail. That is why, when varicose veins are atypical, I also examine the pelvis with duplex ultrasound and, depending on the symptoms, treat the escape point (with foam or microphlebectomy) or the pelvic veins by embolisation.
The SVP classification
Since 2021, pelvic venous disorders have been classified using the SVP system, proposed by an international group of experts. It describes three aspects: the symptoms (S), the varices (V), both pelvic and in the vulva and legs, and the pathophysiology (P): which veins are affected, whether the problem is reflux, obstruction or both, and its cause. Using it ensures that nothing is overlooked and helps choose the right treatment for each patient.
And in men?
The male equivalent of pelvic varicose veins is varicocele, which can also be caused by reflux in the gonadal vein or by compression of the left renal vein.
Frequently asked questions
Why is the pain worse when standing, at the end of the day and before a period?
When standing, gravity makes blood pool in the dilated pelvic veins, and the hormonal changes of the cycle dilate the veins even further. That is why the pain usually improves when lying down.
Is it the same as endometriosis?
No, although both cause chronic pelvic pain and can coexist. That is why it is important for gynaecology to rule out other causes before attributing the pain to pelvic varicose veins.
Does embolisation affect periods or fertility?
In the reference systematic review of 1,308 women, no negative effects on menstruation or fertility were observed, although the quality of the evidence is low.
Is embolisation painful?
It is performed under local anaesthesia and sedation, through a needle puncture in a vein and without incisions. Transient pelvic discomfort in the first few days is common.
Do you see patients from outside Mallorca?
Yes. You can send me your test results: I review them in advance and we hold a first video consultation. Here is how it works.
Videos on this topic (in Spanish)
References
- Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016;27(10):1478-1486.
- Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: a report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568-584.
- De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184-267.
Patient information reviewed by Dr Óscar Merino, vascular surgeon. It does not replace an individual medical assessment.
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Consultation with duplex ultrasound at Clínica Rotger, in the centre of Palma.
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