Dr. Stephen Daugherty recently presented a review of patients treated for Pelvic Congestion Syndrome (PCS) by venous angioplasty and stenting at the largest international meeting of vein specialist ever held. The Union Internationale Phlebologie met in September in Boston with approximately 1600 venous specialists attending. Daugherty and his co-author, Dr. David L. Gillespie of the University of Rochester School of Medicine and Dentistry, reviewed their series of 19 cases of PCS treated over a five year period. Dr. Daugherty presented “Venous Angioplasty and Stenting Improve Pelvic Congestion Syndrome Caused by Venous Outflow Obstruction” which was described by the program chairman as a “game-changer” regarding diagnosis and treatment of pelvic venous disorders.
Pelvic Pain Due to Venous Obstruction
This series of cases is believed to be the first series ever presented in which pelvic pain is due to venous obstruction other than from clotting disorders. Previously, only occasional cases have been reported in the medical literature.
PCS is a chronic condition involving pelvic pain, often worse before or during the menstrual period. Many patients have considerable pain with intercourse (dyspareunia) and some have varicose veins in the external female genitalia (vulva), low back pain, and urinary tract complaints. While many other conditions may cause some of the symptoms more frequently, PCS should be considered if gynecologic exam has ruled out conditions such as ovarian cysts or endometriosis.
PCS is underdiagnosed largely because the common techniques of medical imaging with ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) often miss the abnormalities. Each of these techniques may diagnose enlarged veins in the pelvis when performed by special protocols by experienced technologists and interpreted by physicians experienced in evaluation of venous disorders of the pelvis.
Imaging of veins of the pelvis may show enlarged veins in the pelvis and this has been thought to be due most commonly to failure of one-way valves in the ovarian veins allowing blood to flow downward into the pelvis. The enlarged veins in the pelvis with high venous pressures are associated with pelvic pain much like pain and swelling in the legs due to varicose veins. It has been assumed that an enlarged ovarian vein means that the enlarged veins in the pelvis are due to blood flowing downward (refluxing) with gravity into the pelvis. Dr. Daugherty points out that compression of the left common iliac vein in the pelvis by an overlying artery is much more common in his experience than reflux in the ovarian vein. The enlarged ovarian vein is a pathway for blood from the leg and pelvic organs to pass around the iliac vein obstruction in order to return to the heart.
High quality, detailed pelvic venous ultrasound performed with an external exam is utilized to identify the iliac vein compression and the associated abnormal venous flow patterns. Findings are confirmed with MRI or CT scan with special venous protocols at Gateway Medical Center in Clarksville, Tennessee, and by intravascular ultrasound (IVUS). IVUS is a very detailed look from inside the vein with ultrasound by means of a small catheter passed through a needle-puncture approach. The obstructed pelvic vein is treated with balloon angioplasty (stretching) and placement of a stainless steel stent much like a larger version of stents used in treating obstructions of arteries to the heart.
In the reported series of patients, 15 of 19 experienced complete resolution of pelvic pain and 14 of the 17 sexually active patients experienced complete resolution of their pain with intercourse. Fifteen of the treated patients experienced lower extremity pain and swelling prior to treatment and 13 of the 15 experienced resolution of the leg symptoms as well. The remaining patients reported substantial improvement in their symptoms after treatment.
Dr. Daugherty predicts that PCS due to venous outflow obstruction will be recognized more frequently as clinicians become more familiar with venous obstruction and the special imaging techniques to identify obstruction. Dr. Daugherty requests that potential patients see their gynecologist or primary care physician to evaluate for other possible causes of pelvic pain before scheduling an appointment for pelvic venous evaluation.