Chronic pelvic pain (CPP) affects many women, and often the underlying cause is not gynecological or gastrointestinal. Pelvic Congestion Syndrome (PCS) is a specific vascular condition that frequently contributes to CPP, yet it often remains undiagnosed. PCS involves abnormalities in the veins within the lower abdomen, causing blood flow problems and resulting discomfort.
Defining Pelvic Congestion Syndrome
Pelvic Congestion Syndrome is rooted in venous insufficiency, where veins fail to return blood efficiently to the heart. This condition primarily affects the ovarian veins and sometimes the internal iliac veins, causing them to widen or dilate. Pelvic veins contain one-way valves that prevent backward blood flow. In PCS, these valves are often incompetent or absent. When the valves fail, blood reverses its flow (reflux) and pools in the pelvic veins. This pooling forms pelvic varicose veins, causing the vessels to swell and twist. This engorgement, or congestion, increases pressure on surrounding pelvic structures, leading to chronic pain.
Understanding the Prevalence
PCS is a significant contributor to chronic pelvic pain (CPP). Estimates suggest it accounts for 10% to 40% of all CPP cases. For women whose CPP has no other clear cause, the prevalence may be as high as 30%. Determining the exact prevalence is challenging because PCS is often underdiagnosed or mistaken for conditions like endometriosis or Irritable Bowel Syndrome. Inconsistent epidemiological data collection contributes to the wide range of reported statistics. Factors that increase the likelihood of developing PCS include being of reproductive age and having had multiple pregnancies (multiparity). Hormonal and circulatory changes during pregnancy are thought to permanently weaken vein walls and valves.
Key Symptoms and Patient Experience
PCS is characterized by a distinctive pattern of chronic pain, typically described as a dull ache, heaviness, or dragging sensation in the lower abdomen and pelvis. This discomfort often worsens throughout the day, especially after prolonged standing or sitting, as gravity increases blood pooling. Lying down generally provides relief by reducing pressure on the congested vessels. Pain during sexual activity (dyspareunia) is a frequent symptom, often lasting for an extended period after intercourse. Visible signs of the underlying venous insufficiency can include varicose veins in the vulva or buttocks. Other associated symptoms include an irritable bladder or pain worsening around the time of menstruation. The positional dependence and cyclical nature of the pain are key clues to the condition’s vascular origin.
Diagnostic Procedures
Confirming PCS begins by ruling out other potential causes of chronic pelvic pain, such as gynecological or gastrointestinal issues. Non-invasive imaging is the first step, with transvaginal ultrasound being a primary tool. Ultrasound can reveal dilated ovarian veins, often defined as being greater than 5 to 6 millimeters in diameter, and can detect abnormal, reversed blood flow, especially when the patient performs a Valsalva maneuver. Cross-sectional imaging, such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans, also visualizes the dilated and twisted veins in the pelvis. The definitive method for confirming the diagnosis is catheter-based venography. This minimally invasive procedure involves inserting a catheter and injecting a contrast dye to visualize the pelvic veins under X-ray guidance. Venography is considered the gold standard because it allows physicians to directly observe the blood flow reversal and pooling in real-time.
Current Management Strategies
Initial management for PCS may include conservative measures, such as non-steroidal anti-inflammatory drugs (NSAIDs) or hormonal therapy designed to suppress ovarian function. However, these approaches often provide only temporary or limited symptom relief, and symptoms frequently return upon discontinuation of medication. For definitive relief, attention shifts to minimally invasive, image-guided procedures performed by interventional radiologists. The primary modern treatment is Ovarian Vein Embolization (OVE), which aims to eliminate problematic blood reflux by blocking the insufficient veins. During this procedure, tiny coils or a sclerosing agent are delivered via a catheter into the dilated ovarian and internal iliac veins. This material causes the vein to scar and close off, redirecting blood flow into healthy veins. Embolization is highly effective, with technical success rates nearing 100% and significant long-term symptom improvement reported in 80% to 93% of patients.