Pelvic Congestion Syndrome
What is Pelvic Congestion Syndrome?
Pelvic venous congestion syndrome is also known as ovarian vein reflux. It is a cause of chronic pelvic pain in approximately 13-40% of women. Chronic pelvic pain is pain in the lower abdomen which has been present for more than 6 months. Pelvic congestion syndrome is therefore a painful condition often caused by dilatation of the ovarian and/or pelvic veins(rather like varicose veins but in the pelvis) . Varicose veins are commonly seen in the legs when the veins become less elastic and the valves that stop the blood from flowing backwards stop working. This causes the blood to pool, due to gravity, causing enlarged, bulging and knotty veins. This is also what happens to the pelvic veins in pelvic venous congestion syndrome (PVCS). This pressure results in the pain of PVCS and may also cause visible varicose veins around the vulva, vagina, inner thigh, sometimes the buttock and down the leg (s).
In order to understand what veins are dilated and why you get varicose veins in around the vulva/vagina and down the inner thigh it is important to know a little bit about the anatomy.
The diagram below (Diagram 1) demonstrates the normal anatomy of the veins within the body.
Diagram 1: Normalvenous anatomy: Normally the blood is pumped from the legs, through the veins in the pelvis and abdomen to the heart. The blood normally flows from the ovaries through the ovarian veins. The right ovarian vein joins the inferior vena cava and the left ovarian vein joins the left renal vein.
When the valves in the vein stop working or there is obstruction to the flow of the blood in the veins going back to the heart, the blood then flows backwards (i.e. the wrong way, away from the heart). This causes the varicose veins in the pelvis around the ovaries, vulva/vagina and down the inner thigh and legs, causing PVCS. Look at Diagram 2 and 3 which show what happens when the veins become abnormal.
Diagram 2: Shows how the dilated vein looks and causes the varicose veins around the ovary because the valves don’t work. Blood flow is in the wrong direction, pooling in the veins and causing them to enlarge.
What are the causes of PVCS?
The cause of the dilated ovarian/pelvic veins in PVCS is poorly understood.PVCS most commonly occurs in young women , and usually in women who have had at least 2-3 children. During pregnancy the ovarian vein can be compressed by the enlarging womb or enlarged because of the increased blood flow. This is thought to affect the valves in the vein causing them to stop working and allowing the blood to flow backwards, contributing to PVCS.
There are other causes that may cause obstruction to the ovarian and pelvic veins leading to PVCS, which are much less common, and are the result of vein obstruction. PVCS may also be associated with polycystic ovaries.
The absence of the vein valves due abnormal development may be a contributing factor.
What are the treatment options?
The usual treatment is percutaneous transcatheter pelvic vein embolisation. This is a minimally invasive treatment that is safe and can be done as a day-case. You come in for the procedure in the morning and can leave a few hours later the same day. In most cases it is the ovarian vein that is the cause of the varicose veins. However other pelvic veins such as veins called the internal iliac vein, internal pudendal vein, obturator vein and ischial veins may also be responsible and need treating as well.
Other treatment options are open or laparoscopic surgery to tie the culprit veins. Both these procedures are more invasive than ovarian vein embolisation and require a general anaesthetic and a longer recovery period.