PELVIC CONGESTION SYNDROME:
Pelvic Congestion Syndrome (PCS) is a potential cause of chronic pelvic pain in young women who commonly have had children.
The chronic pelvic pain is caused by reflux of blood down the incompetent gonadal veins resulting in dilated pelvic veins (varicosities). The symptoms are similar to the male equivalent known as a Varicocele, but because the dilated veins are not externally visible or palpable the diagnosis can be elusive. The diagnosis is further complicated by the fact women typically suffer from cyclical pelvic pain.
Pelvic congestion syndrome affects over 10-25% of women who have had 2-3 children. The exact cause is poorly understood but in 60% of cases women have incompetent gonadal veins causing pelvic vein dilatation and pain. The hallmark symptom is dull, aching lower abdomen exacerbated by long periods of sitting or standing often accompanied with feelings of fullness in the legs. The symptoms are typically mild in the morning and progress during the day and can be associated with feelings of urinary frequency and pain on micturition. Very occasionally the dilated veins can extend onto the perineum and cause varicose veins of the vulva.
What is the treatment for Pelvic Congestion Syndrome?
Patients are frequently referred to a Gynaecologist for initial assessment and exclusion of other causes of chronic pelvic pain. If PCS is considered then typically a pelvic ultrasound scan is performed to look for dilated pelvic veins. If these veins are present then either MRI or CT venography is performed to demonstrate the anatomy of the gonadal veins, exclude alternative diagnoses and aid planning treatment pathways.
Prior to the availability of minimal invasive therapies performed by Interventional Radiologists (IR’s) the treatment was either medical with hormonal manipulation or hysterectomy with the accompanying morbidity. Embolisation of the gonadal veins is now the primary treatment and is performed as a day-case commonly only under local anaesthetic. A special catheter and guidewire is introduced via a vein in your groin or neck through a 1-2mm incision to the gonadal (ovarian) veins. Venography (picture of the veins) is performed to demonstrate the dilated pelvic veins and then small “springs” known, as coils are deployed blocking the vein and preventing the reflux that causes the chronic pelvic pain. The procedure is very safe but as with all medical procedures there are some risks. The main risk with this procedure is failure and embolisation coil migration. If migration occurs then usually the coil can be retrieved but occasionally it ends up in a safe place that will not cause any serious problems.
When will patients require Gonadal (Ovarian) Vein Embolisation performed?
Gonadal vein embolisation is typically performed once the Gynaecologist and Interventional Radiologists are happy that this is the most likely cause of the chronic pelvic pain. The precise diagnosis is made during gonadal vein and pelvic venography (picture of the veins using a catheter placed inside them), which can be performed just prior to the embolisation procedure or on a separate visit. Treatment is only performed on patients with typical symptoms and imaging findings of incompetence of the gonadal veins. Technical success is reported in 98% of cases with recurrence rates of less than 8%.
What happens during the gonadal (Ovarian) vein embolisation procedure?
Gonadal vein embolisation is a minimally invasive procedure performed by a specially trained interventional radiologist in the interventional radiology suite. You will lie on your back during the procedure and you may also be connected to equipment to monitor your heart beat and blood pressure. During this procedure, the interventional radiologist inserts a tube (catheter, a long thin plastic tube, usually around 2 mm in diameter into a vein). This is commonly done using a vein at either your groin or neck. Local anaesthetic is used to numb the skin before the procedure. You will feel a slight pin prick when the local anaesthetic is injected. You may feel slight pressure when the catheter is inserted but no serious discomfort.
Using the X-ray for image guidance the catheter is positioned into the gonadal veins and contrast is injected to confirm incompetence. If an abnormality is shown, the same catheter can be used for treatment to deliver the embolisation coils and block the abnormal vein. In a small percentage of cases, the procedure is not technically possible and the catheter cannot be positioned appropriately. If this occurs then another approach may be required. At the end of the procedure the catheter is removed and pressure is applied to the area to stop any bleeding. You will typically need to stay in bed for 1hr post procedure.
How should I prepare?
Gonadal vein embolisation is carried out as a day case procedure under local anaesthetic. You may be asked not to eat for 4hrs before the procedure, although you may still drink clear fluids such as water. If you have any allergies or have previously had a reaction to the dye (contrast agent), you must tell the radiology staff before you have the test.