Pelvic Congestion Syndrome (PCS)
What is pelvic congestion syndrome?
We most commonly think about varicose veins affecting the legs, but it is also possible to develop a similar condition in veins in other parts of the body. When reflux occurs in the ovarian and pelvic veins they can become tortuous and dilated (just like varicose veins in the leg). The effects of the venous engorgement, perhaps by pressing on other structures and organs in the pelvis, can give rise to a host of symptoms, such as irritable bowel syndrome and painful periods. But in particular, pelvic congestion syndrome is likely to be a hugely under-recognised cause of chronic pelvic pain.
Why does pelvic congestion syndrome occur?
The "one-way" flow in veins is ensured by small valves, which should only allow the passage of blood in one direction, back to the heart. Malfunction of the valves allows blood to pool in the veins, and this causes the vein wall to stretch over time, and enlarge (See figure 1). Nobody fully knows why this valve malfunction develops in the first place, although the condition is more common in people who have been pregnant because of the increased blood flow in the pelvis and the compression of the vein as the pregnant uterus expands.
How is pelvic congestion syndrome diagnosed?
Quite often investigations and tests will already have been carried out to try and elucidate an explanation for the symptoms. Because of the way in which pelvic congestion syndrome can present, patients are often initially seen by a gynaecologist, whose special expertise is in the management of disorders of the female reproductive system. In fact, chronic pelvic pain makes up 10-40% of gynaecological outpatient referrals. Sometimes an unrelated cause is discovered to explain the pelvic symptoms (such as endometriosis), or the dilated pelvic veins happen to be picked up on one of the tests that the gynaecologist organises. Where no explanation can be found for the symptoms, different investigations can be performed with the specific aim of looking for pelvic congestion syndrome. The vascular specialist may recommend a magnetic resonance venogram (MRV), a trans-vaginal ultrasound, or frequently a combination of these modalities.
What happens at consultation?
On your first consultation, your specialist will enquire about your symptoms and how they affect your life. They will go on to ask you questions related to your medical history to look for any potential problems in how you will be treated. They may well ask questions related to your occupation and any planned holidays if surgery is going to be performed. The consultant will explain to you the benefit and risk of the interventions he/she has recommended, which will allow you to make an informed decision as to your care.
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Fig 1: Pelvic congestion syndrome
(click image to enlarge)
How is pelvic congestion syndrome treated?
If the investigations show features in the pelvic and ovarian veins that are consistent with the diagnosis of pelvic congestion syndrome, then the aim of any intervention is to relieve the venous reflux and pooling. This is most commonly achieved with a minimally invasive, X-ray guided procedure called embolisation; small metal coils are deposited within the malfunctioning veins via a small needle placed in the groin. These embolisation coils cause the veins to occlude so that the pressure from the venous congestion is relieved. This doesn't cause any detriment to the circulation because the veins are already faulty to begin with, so are not contributing usefully to the circulation by this stage. Risk: •As with all operations/procedures there are potential risks of complication. •There can be bleeding from incisions and punctures, bruising, phlebitis (inflammation of the veins) and infection. There is also a low risk of developing deep vein thrombosis (DVT), which is primarily of concern because of the subsequent risk of pulmonary embolism (PE), which is a potentially serious complication.