Pelvic Congestion Syndrome
According to the Society of Interventional Radiology, “it is estimated that one-third of all women will experience chronic pelvic pain in their lifetime”. Many of these women are told the problem is “all in their head” but recent advancements now show the pain may be due to varicose veins in the pelvis, known as pelvic congestion syndrome.
The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don’t close properly, allowing blood to pool in the pelvis causing pressure and bulging veins.
- Women with pelvic congestion syndrome are typically less than 45 years old and in their childbearing years.
- Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
- Chronic pelvic pain accounts for 15 percent of outpatient gynaecological visits.
- Studies show 30 percent of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15 percent have PCS along with another pelvic pathology.
- Two or more pregnancies
- Nut cracker syndrome -The nutcracker syndrome(NCS) results most commonly from the compression of the left renal vein between the abdominal aorta (AA) and superior mesenteric artery (SMA), although other variants exist. The name derives from the fact that, in the sagittal plane and/or transverse plane, the SMA and AA (with some imagination) appear to be a nutcracker crushing a nut (the renal vein).
- May Thurner Syndrome –May-Thurner syndrome(MTS), also known as the iliac vein compression syndrome, is a condition in which compression of the common venous outflow tract of the left lower extremity may cause discomfort, swelling, pain or blood clots (deep venous thrombosis) in the iliofemoral veins.
The chronic pain that is associated with this disease is usually dull and aching. Pain is usually felt in the lower abdomen, pelvis and lower back and is described as heaviness, dragging, radiating to the tail bone, buttocks and thighs. Pain can be constant with worsening :
- During and following intercourse
- Before and during the menstrual cycle
- When standing for long periods of time (worse at the end of the day)
Other symptoms may include:
- Frequency of urination
- Varicose veins on vulva, buttocks or thigh.
Diagnosing Pelvic Congestion Syndrome
An interventional radiologist may use the following imaging techniques to confirm pelvic varicose veins that could be causing pelvic pain.
1) Computed tomography venography – More objective and gives a good overview of size of ovarian and pelvic veins and any other pelvic pathology, but does involve giving intravenous contrast and radiation.
2) Pelvic Ultrasound – subjective but can be diagnostic if done well by an experienced sonographer.
3) Pelvic venogram – is the gold standard and can be done at the time of embolisation or in cases where the symptoms are present but the CTV and ultrasound are negative.
Analgesics may be prescribed to reduce the pain. Certain hormones may be helpful in controlling symptoms in the short term but can cause side effects such as weight gain.
Depending on surgeons’ preferences, surgical options include a laparoscopic or an open operation, tying off or removing the veins.
Your Treatment with Endovascular WA
Endovascular WA provides a minimally invasive procedure called Ovarian Vein Embolisation. In addition to being much less invasive, embolisation has been shown to be a a safe and effective treatment. It is technically successful in 95-100 percent of cases. A significant percentage of women improve in their symptoms (upto 80%) after the procedure. In some cases vulval and leg veins may require further treatment.
During the procedure, Endovascular WA’s interventional radiologist inserts a thin catheter into the femoral vein in the groin and guides it to the affected pelvic vein using X-ray guidance. To seal the faulty and enlarged vein, soft coils made of platinum and a sclerosing agent (the same type of material used to treat varicose veins) are used to close the vein The coils remain within your body. After treatment, patients may return to normal activities within a few days.
Prior to a procedure for the treatment of pelvic congestion syndrome, patients are required to complete the following
- Ensure you have someone to take you to and from the hospital on the day of your procedure.
- Make sure you have returned your signed information to our reception.
- Have a shower on the morning of your procedure and wear loose, comfortable clothing.
- Remain fasted for 8 hours before the procedure
- Make yourself familiar with the procedure and ask any questions you are not sure about before the procedure
Post Procedure Patient Care
Post-Procedure: What to expect
The procedure is normally performed under conscious (“twilight”) sedation or a general anaesthetic in some cases. After a short period of recovery from sedation in the hospital, patients normally return home on the same day. Patients should not drive themselves home.
During the recuperation phase at home, the patient should remain well hydrated. Normal activity can be resumed the following day, but please refrain from heavy lifting or strenuous exercise such as running and lifting weights for 1 at least 1 week. There may be some mild discomfort in the flank and pelvis in the following week. This should settle with paracetamol, anti inflammatories and rest. The following menstrual cycles may also be uncomfortable as there is some re-adjustment of the flow dynamics.
Follow up with Dr Nadkarni should be performed if you suffer from varicose veins in the legs. These will still require treatment however the outcome is likely to be more sustained when the “leak” from the ovarian system is treated.
Panadol, Codeine and an anti-inflamatory (Voltaren) may be required for a few days. Severe pain or fever not controlled by the pain killers should be reported to our rooms.
How much activity should I do after the procedure?
On return home you could go for a short 10 minute walk the same evening. Take a couple of Panadol (if needed) and rest if required.
Over the next week, you should make a point of remaining mobile.
Avoid prolonged sitting, standing , and any non essential air travel over the following month.
When to call our rooms?
If the pain or fever persists, even after taking all oral pain medications, please call us.
If you cannot get through to our office or your symptoms occur over the weekend or after hours please go directly to your closest Emergency department and let them now that you have had a pelvic vein embolization procedure.
If you intend to fly in the month following the procedure, please inform our clinic so you can be supplied with a blood thinner (Clexane) which will reduce your risk of Deep Vein Thrombosis (DVT).
How long does it take to fully recover?
Ovarian Vein Embolisation may take upto 1 month to fully recover. Patients can usually resume normal activities within a week after the procedure. The pelvis may take up to 3 months to readjust.
Please call the clinic to arrange for a follow-up visit 3 months after the procedure.
Please call sooner if you wish to make an earlier appointment.
Problems and Potential Complications
Post embolisation syndrome – pelvic and lower back pain (similar to pre-treatment symptoms) which may last from days to weeks. Fever, which usually settles with paracetamol. This is due to ongoing inflammation in the treated pelvic veins and can take some time to settle. Symptoms usually settle with rest and anti-inflammatories.
If symptoms are severe please contact the clinic on (08) 9284 2900 or if it is after hours please contact your local emergency department and let them know that you have had a recent ovarian vein embolisation.
- Coil migration – extremely rare (<1%). May travel to lungs, can be potentially retrieved.
- Inadvertent embolisation – extremely rare (<1%). Coils prolapsing into renal vein and ovarian vein tributaries.
- Pelvic infection – extremely rare.
- Pelvic haemorrhage – extremely rare.
- Allergy to coils and sclerosants – extremely rare.
- Anaphylaxis – extremely rare.
- DVT – extremely rare.
The coils that are placed in the veins are permanent and remain within your body. (These are made from platinum/ tungsten alloy) and have been used in medical procedures called embolization for many decades and are TGA approved.
Statistics regarding the ovarian vein embolization procedure also show that 10 -15 % of patients may not see any significant improvement in their symptoms and 1% or less may actually notice their symptoms worsen.