Pelvic Congestion Syndrome (PCS)
Pelvic Congestion Syndrome (PCS)/ Chronic Pelvic Pain (CPP)
Chronic pelvic pain (CPP) is a significant and common disorder in women. It is estimated that a third of all women will experience chronic pelvic pain during their lifetime. Greater than 9 million women in the US suffer from CPP. CPP specifically due to ovarian and pelvic varices is known as pelvic congestion syndrome (PCS). Up to 15% of women between the age of 20-50 years have varicose veins in the pelvis and 60% of these women are symptomatic.
What is Pelvic Congestion Syndrome (PCS)?
PCS is a cause of chronic pelvic pain in women. It is defined as “non-cyclic” pain often lasting greater than 6 months. It is usually a dull ache deep in the pelvis that is worst after being in upright positions (sitting, standing, walking or running). Pain may radiate to the lower back and down the thighs. The pain may worsen leading up to menstrual period. Menstrual cycles can be heavy and painful with long duration. It is common for some women to have pain during or after sexual intercourse or even with a full bladder or bowel. Lying down may provide some alleviation of the pain. PCS is quite commonly seen in women with multiple pregnancies. Varicose veins may also be present along the buttocks, genital region or legs. PCS is seen in 15-18% of women who concurrently suffer from varicose veins of the legs.
What causes PCS?
Normal venous valves prevent backward flow and ensure blood returns to the heart in one direction. Similar to the dysfunctional valves in the superficial veins of the legs, which lead to venous insufficiency and varicose veins, defective or damaged valves in the ovarian veins result in blood flowing backwards (reflux) causing congestion and raised venous pressure in the pelvis. Pooling of stagnant blood results in engorged, dilated and stretched pelvic veins, all leading to CPP.
How is PCS diagnosed?
PCS is under-recognized and under-diagnosed by clinicians as a source of CPP in women. CPP can be caused by a variety of conditions, including endometriosis, adenomyosis, IBS, pelvic infection and adhesions. The diagnosis of PCS is often delayed in the search to rule out more serious conditions such as infection, inflammation or cancer which can cause pelvic pain. Depending on what other symptoms are present, gynecological examination, PAP smears and rectal examination might have been done by your doctor. Further investigations like colonoscopy and laparoscopy might also have been done. In PCS, these tests are usually negative. Pelvic ultrasound and CT scan are common initial tests however these may be reported as normal, unless signs of PCS were specifically looked for. The definitive gold standard test is a venogram, a minimally invasive procedure performed on an outpatient basis.
How is PCS treated?
Medical treatment with hormone analogues and analgesics has not shown to be effective long term.
Hysterectomy is major surgery with prolonged recovery of numerous weeks and increased risk of complications such as infection or bleeding. Furthermore, hysterectomy is associated with residual pain in 33% of patients and a 20% recurrence rate. It is not the right treatment for PCS.
Open or laparoscopic ligation (tying off) of ovarian vein is effective in 80% of patients but it is an invasive and difficult operation. Recurrence is a problem if ligation is performed too high.
Ovarian vein embolization (OVE) is a minimally invasive procedure often performed along with the venogram. It involves blocking of one or both refluxing ovarian veins internally. For the past 15 years, this treatment has been associated with good clinical outcomes in most women suffering from the symptoms of PCS. The procedure is technically successful in almost 100% of patients. Symptomatic improvement tends to be seen in >80% of patients undergoing OVE.
What are the advantages of OVE over surgery?
Embolization is as effective as surgical ligation of the ovarian vein but is much less invasive and less risky. It does not require major incisions therefore reducing risk of infection, allowing for faster recovery and less pain. No general anesthetic is required. After embolization, patients can resume normal activity in 1-2 days. Depending on the type of surgery, surgical recovery is significantly longer than embolization, often weeks.
How is OVE performed?
OVE is performed at Desert Endovascular Surgical Center on an outpatient basis under light sedation, usually requiring a 2-3 hour stay. Dr. Rami has particular interest in Women’s Health and specializes in the evaluation, diagnosis and treatment of PCS. He has performed several hundred embolization procedures.
A light sedation is given by our board-certified anesthesiologists. Either the jugular or femoral vein is used for entry. The overlying skin is numbed using local anesthetic and a tiny nick is made. A catheter is inserted and negotiated into the ovarian vein on each side under X-ray guidance. A diagnostic venogram is performed by injecting contrast (X-ray dye) to identify the veins and the direction of blood flow. Once backward flow or reflux is confirmed, the vessel is permanently blocked with stainless steel or platinum coils fed through the catheter. Often times, a sclerosing agent (such as polidocanol) is injected between coils to ensure long term blockage of the refluxing veins. No incisions or stitches are required and there is no sensation inside while this is happening. The procedure takes about an hour but can be longer if additional refluxing veins are found in the pelvis that also need to be treated.
What are the complications with embolization?
OVE is a very safe and effective procedure. Minor complications although uncommon may include bruising at the entry site, backache and pelvic pain. Vessel injury and allergies to contrast or drugs given during the procedure are rare.
What happens after the procedure?
Bed rest for 1-2 hours until the sedation has worn off. Patients will need to arrange transport, as they are not allowed to drive for 24 hours after sedation. Rest with light activity is recommended for the rest of the day. Normal activities can be resumed the following day. Strenuous exercise should be avoided for a few days. Some patients might experience back and pelvic pain after embolization which can be controlled with non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen.
Dr. Rami likes to see his patients back in one week for post-operative follow-up, then at 1 and 3 months.