Pelvic varicosities, pelvic varices and ovarian reflux are present in 40% of women suffering from chronic pelvic pain (A pain in the abdomen that lasts for more than 6 months). This condition is similar like varicose veins we see in the legs but actually the veins are of the ovaries.
What causes Pelvic Congestion?
The reflux (reversal of flow) in these veins causes blood to pool in the pelvis especially around the ovaries, vulva, vagina, inner thigh and sometimes around the buttocks. This pooling causes the veins to dilate, bulge out and become knotty. As the veins dilate, they cause more pooling of blood. Thus it is called as Pelvic Venous Congestion Syndrome (PVCS).
The valves that prevent backwards flow are either absent or become incompetent. In pregnant women, there is an increased blood flow and zone veins swell due to pregnancy. When the veins swell, the size of vein valves remain same but reflux is expected. However, this should go away after childbirth. If it doesn’t go away, you will have PVCS.
Another cause of PVCS can be a polycystic ovarian disease.
In males, it leads to varicocele. As the testis reside outside, the pelvis in males, barring varicocele and other symptoms usually do not manifest in males.
What are its Symptoms?
- Pelvic and Lower abdominal Pain
- Dragging sensation in the pelvis
- Worsening stress incontinence
- Pain while standing
- Severe pain during sexual intercourse
- Pain and fullness in the pelvis that may go right down to the legs
- Vulvar varicosities
How can the Condition be diagnosed?
- A complete history and physical exam with full exposure of the patient will reveal signs of PCVS as vulval and vaginal varicosities.
- Imaging (Color Doppler ultrasound, CT angiogram, MR Venogram) these can make the diagnosis. Dr. Digvijay Sharma says that unless the ordering physician specifically requests a gonadal venous scan these are easily missed in routine.
- The gold standard of making/ruling out the diagnosis is formal deep venogram. I usually gain access to the deep venous system from the neck and reach the gonadal veins, inject a contrast material that lights up the ovarian vein and confirms/rule out the diagnosis.
The beauty of this procedure is that the reverse flow system can be closed right at the time we make the diagnosis with coils, chemicals or embolization particles.
What are the management options?
Usually, patients do not want to undergo surgical procedures and request for medical management. Medical management can reduce the pain and size of the varicosities in 75% cases. I MUST STRESS THAT THE ROOT CAUSE OF REFLUX IS NOT ADDRESSED HERE. The pain and size of veins can be reduced with medications but these are not over the counter self-prescription drugs so one needs to be aware.
Do the Endovascular Procedures involve risk?
This is the only procedure that addresses the root cause of the PVCS – The Reflux. It is successful in almost all the cases and has a success rate of 90%. This means 90 of 100 PTS treated will be free of disease for 10 years but the remaining 10 will require a repeat procedure in 10 years for recurrence.
The procedure does not involve any risk. There are some risks associated with this procedure as mentioned below. They are very minimal and occur only in about 1 in 500 cases.
- Allergy to the contrast material.
- Infection after the embolization procedure
- Bleeding injury to target vessel
- Non-target embolization (distinctly rare) here vessel other that the intended one is embolized.
- Radiation exposure
Endovascular management is the only option that addresses the cause even though medicines will decrease the symptoms in 75% cases. This is a day care procedure and general Anesthesia is usually not needed.