Female pelvic congestion syndrome: how can CT and MRI help in the management decision?

Imaging-Based Approach to Venous-Origin Chronic Pelvic Pain

Chronic pelvic pain (CPP) is a debilitating condition affecting up to 26% of women worldwide. Among its many causes, pelvic venous disorders (PeVD) is increasingly recognized as an underdiagnosed contributor, often overlooked due to its non-specific presentation. PeVD results from venous reflux, or obstruction, leading to venous hypertension, congestion, and chronic pain. Advanced imaging techniques play a pivotal role in diagnosing PeVD, differentiating it from other etiologies of CPP. Ultrasound, particularly Doppler imaging, serves as the firstline modality for assessing venous reflux and dilation. Computed tomography and magnetic resonance venography provide detailed anatomical and haemodynamic evaluations, aiding in the identification of compressive syndromes and collateral pathways. Selective venography remains the gold standard, offering real-time visualization of reflux severity and guiding minimally invasive interventions such as venous embolization. Despite these advances, PeVD remains underrecognized in clinical practice, leading to delays in diagnosis and management. Increased awareness and standardized diagnostic criteria are crucial for improving patient outcomes. A multidisciplinary approach incorporating radiologists, gynecologists, and vascular specialists is essential for the comprehensive evaluation and treatment of PeVD. Emerging therapies, including endovascular techniques, offer promising options for symptom relief, reducing the need for invasive surgical procedures. This review highlights the pathophysiology, imaging modalities, and evolving management strategies for PeVD, emphasizing the importance of early recognition and intervention in patients with CPP.

Pelvic Varicose Veins in Women. Russian Experts Consensus

Pelvic Varicose Veins in Women. Russian Experts Consensus.

Ultrasonography in the diagnosis of pelvic vein insufficiency, a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis to investigate the efficacy of ultrasonography in the diagnosis of pelvic vein insufficiency (PVI).

RESULTS

Seven studies comprised of 802 patients were included. Of these studies, 5 utilised transvaginal ultrasound (TVU), 1 utilised transabdominal ultrasound (TAU) and 1 utilised both ultrasounds as diagnostic tool .The overall pooled sensitivity and specificity was 0.96 and 0.84 respectively. The sensitivity and specificity for TVU were 0.96 and 0.86. The pooled sensitivities between studies employing a <7 mm cutoff in pelvic veins' diameter (PVD) and those employing a >7 mm threshold were 0.99 and 0.94 while the pooled specificities were 0.75 and 0.96 respectively.

CONCLUSION

The evidence supports the efficacy of ultrasonography in the diagnosis of PVI. A threshold of up to 6 mm in PVD yielded excellent sensitivity outcomes, but it is at the expense of specificity. This meta analysis suggests that a PVD threshold of 7 mm should be employed as a cutoff point in the diagnosis of PVI, displaying both excellent sensitivity and specificity outcomes.

Noninvasive diagnostic imaging of pelvic venous disorders

It is estimated that chronic pelvic pain (CPP) may affect up to 24% of women. Unfortunately, very often, despite extensive diagnostics, the cause of CPP remains unknown. The pathophysiology of CPP could be explained to a large extent by the occurrence of pelvic venous disorders (PVD). Although pelvic venography is still considered the gold standard for the diagnosis of PVD, noninvasive diagnostic imaging techniques seem to be instrumental in the initial identification of patients with PVD. This literature review aimed to analyze and evaluate the usefulness of noninvasive diagnostic imaging techniques like transvaginal ultrasonography, transabdominal ultrasonography, magnetic resonance, and computed tomography in the diagnosis and identification of patients with PVD. Forty-one articles published between 1984 and 2023 were included in this literature review. Based on this literature review, we conclude that the clinical application of noninvasive diagnostic techniques in the diagnosis of PVD seems to be very promising. Future studies investigating the role of noninvasive diagnostic imaging techniques in the diagnosis of PVD are required.

Pelvic venous disorders in women - diagnosis and therapy

Chronic pelvic pain may cause a significant reduction in the quality of life for affected women, and the extent of the limitation is often underestimated. Chronic pain can lead to lifelong problems. Currently, PCS is probably significantly underdiagnosed as a cause of chronic pelvic pain in women. To diagnose PCS, other common causes of chronic pelvic pain must be excluded and typical changes in pelvic vein syndrome must be detected, ideally using MR phlebography. If the indication is correct and the procedure is carried out appropriately - ideally by experienced interventionalists certified according to DeGIR/EBIR - the symptoms can be eliminated in the long term with a high success rate and few complications. Simultaneous psychotherapeutic treatment should always be discussed with the patients. · PCS is a common cause of chronic pelvic pain in women.. · Imaging requires Doppler sonography and contrast-enhanced magnetic resonance angiography.. · Typical symptoms and dilated pelvic veins (>8 mm) indicate interventional therapy.. · Pathological pelvic veins are embolized using coils and alcohol foam.. · Published success rates and long-term results suggest propagating interventional therapy.. · Paulus T, Minko P, Petersen T et al. Pelvic venous disorders in women - diagnosis and therapy. Fortschr Röntgenstr 2024; DOI 10.1055/a-2446-0749.

Pelvic congestion syndrome analysis through quantitative 2-dimensional phase-contrast MRI: a promising vision from an observational cohort study

BACKGROUND

To examine the application of quantitative 2-dimensional phase-contrast MRI (2D PC-MRI) for treating patients with pelvic congestion syndrome (PCS).

MATERIALS AND METHODS

The authors conducted a retrospective cross-sectional analysis by using quantitative 2D PC-MRI data enrolled between April 2017 and September 2023. In addition, 32 healthy female controls (HCs) were included.

RESULTS

Most patients with PCS presented with chronic pelvic pain and more than half had extrapelvic venous symptoms (80/81, 98% and 45/81, 56%, respectively). Quantitative 2D PC-MRI analyzed the 81 patients with PCS, 239 patients without PCS, and 32 HCs. The patients with PCS had higher stroke volume (SV), absolute SV (ASV), and mean flux (MF) in the calf region (interstitial pixel shift) than did the HCs. In the left gonadal vein, the patients with PCS had higher SV, backward flow volume (BFV), ASV, and MF and lower forward flow volume (FFV), stroke distance (SD), and mean velocity (MV) than did the HCs. However, the patients with PCS had lower SV, FFV, MF, SD, and MV in the great saphenous veins. Quantitative 2D PC-MRI analysis revealed that the PCS group had higher SV, FFV, BFV, ASV, and MF in the calf region than did the non-PCS group. The variables that most strongly differentiated the patients with PCS from the HCs were SV in the great saphenous veins, SD in the great saphenous veins and left gonadal vein, and MV in the great saphenous veins and left gonadal vein. Caudal flow in the left gonadal vein was identified in half of the patients with PCS (39/81, 48.1%); 14 of them received embolization for left gonadal vein.

CONCLUSIONS

In additional to providing an objective 3-dimensional morphology of the pelvic veins and extrapelvic leaks, quantitative 2D PC-MRI analysis reveals distinct hemodynamic profiles between patients with PCS, those without PCS, and HCs, especially in the gonadal veins and regional perfusion of the calves.

Diagnosis and Management of Pelvic Congestion Syndrome: Comprehensive Review

BACKGROUND

Pelvic congestion syndrome (PCS) is a poorly understood condition that can be associated with chronic pelvic pain and could impact quality of life. The diagnosis is often made by exclusion of other causes of pelvic pain.

OBJECTIVE

The purpose of our review was to provide an update on the etiology, anatomy, physiology, identification, and the therapeutic management of PCS.

METHOD

We conducted a literature review involving publications from 2003 to 2024 in PubMed, Elsevier, MEDLINE, as well as manual searches of primary and review articles using keywords such as "pelvic veins", "embolization", "venography", "pelvic congestion syndrome", and "chronic pelvic pain".

CONCLUSION

PCS remains poorly understood. Symptoms can be non-specific and difficult to distinguish from other diseases; yet it is an important cause of chronic pelvic pain in women. To date, there have been only a small number of randomized trials and high-level evidence is still lacking.

OUTLOOK

We call for an increased awareness of PCS and additional clinical studies in a large number of patients.

Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options

Pelvic venous congestion syndrome (PVCS) is a common, but underdiagnosed, cause of chronic pelvic pain (CPP) in women.PVCS occurs usually, but not exclusively, in multiparous women. It is characterized by chronic pelvic pain of more than six months duration with no evidence of inflammatory disease.The patients present to general practitioners, gynaecologists, vascular specialists, pain specialists, gastroenterologists and psychiatrists. Pain of variable intensity occurs at any time but is worse in the pre-menstrual period, and is exacerbated by walking, standing, and fatigue. Post coital ache, dysmenorrhea, dyspareunia, bladder irritability and rectal discomfort are also common. Under-diagnosis of this condition can lead to anxiety and depression.A multidisciplinary approach in the investigation and management of these women is vital.Non-invasive imaging (US, CT, MRI) are essential in the diagnosis and exclusion of other conditions that cause CPP as well in the definitive diagnosis of PVCS. Trans-catheter venography remains the gold standard modality for the definitive diagnosis and is undertaken as an immediate precursor to ovarian vein embolization (OVE). Conservative, medical and surgical management strategies have been reported but have been superseded by OVE, which has a reported technical success rates of 96-100%, low complication rates and long-term symptomatic relief in between 70-90% of cases.The condition, described in this paper as PVCS, is referred to by a wide variety of other terms in the literature, a cause of confusion.There is a significant body of literature describing the syndrome and the excellent outcomes following OVE however the lack of prospective, multicentre randomized controlled trials for both investigation and management of PVCS is a significant barrier to the complete acceptance of both the existence, investigation and management of the condition.