Pelvic Congestion or Hypertension Syndrome

Pelvic venous congestion syndrome (PVCS) is a cause of chronic pelvic pain and is a secondary cause of leg varicose veins in approximately 13-40% of women. Pelvic congestion syndrome is condition often caused by the dilatation of the ovarian or other pelvic veins, like varicose veins but in the pelvis.

However, in almost all cases, the treatment of pelvic congestion syndrome is very simple.

Varicose veins are most commonly seen in the legs. They occur due to a failure of the valves in the leg veins (see varicose vein information sheet for more details). This causes the blood to pool, causing enlarged, bulging and dilated veins. This is also what happens to the pelvic veins in PVCS. This pressure can cause a number of abdominal or pelvic complaints but can also be a cause of lower limb varicose veins and swelling, through the indirect pressurisation of leg veins.

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Ovarian vein incompetency (graphically and on MRI)

In men, PCVS through the malfunctioning of a testicular or gonadal vein (the male equivalent of the ovarian vein), can cause dilated veins in the testicles (varicocele), testicular discomfort, infertility and varicose veins. This is treated in a similar fashion to PCVS.

Another associated condition is May-Thurner Syndrome. This condition can cause PCVS but can more commonly cause left leg swelling and can be a cause of deep vein thrombosis (DVT). This is caused by compression of your left iliac veins by your iliac arteries causing blood to pool in your leg. Whilst a minimal degree of compression is present in all of us, in rare cases the compression is severe and needs treatment.

May Thurner Syndrome (Illiac Vein Compression by Illiac Artery)

Causes of Pelvic Venous Congestion Syndrome

The cause of the dilated ovarian/pelvic veins in PVCS is poorly understood. PVCS most commonly occurs in women who have had children. During pregnancy, the ovarian vein can be compressed by the enlarging womb or enlarged because of the increased blood flow. This is thought to affect the valves in the vein causing them to stop working. This causes poor pelvic drainage and pooling of blood in the pelvic veins.

There are other causes that may cause obstruction to the ovarian and pelvic veins leading to PVCS, which are much less common. It can also occur spontaneously or associated with an aberrant venous anatomy. PVCS may also be associated with polycystic ovaries. The absence of the vein valves due to abnormal development may also be a contributing factor.

Symptoms and Signs of PVCS

The varicose veins in the pelvis surround the ovary and can also push on the bladder and rectum. This can cause the following symptoms:

  • Pelvic pain or aching around the pelvis and lower abdomen
  • Dragging sensation or pain in the pelvis
  • Feeling of fullness in the legs or abdomen
  • Bloating
  • Worsening of stress incontinence
  • worsening in the symptoms associated with irritable bowel syndrome
  • Atypical leg, buttock or vulval varicose veins
  • Haemorrhoids

Seeing Dr Ponosh

Your GP may contact Dr Ponosh’s office directly, however in some cases they will provide you a referral to contact the office yourself. Dr Ponosh’s caring and helpful staff will walk you through the process of making an appointment with Dr Ponosh. His staff may also contact you directly. For further information regarding referrals, click here.

If you have any questions, please do not hesitate to contact our friendly team on (08) 9386 6200.

Diagnosing Pelvic Congestion Syndrome

When you see Dr Ponosh, he will undertake a full history and appropriate examination. In cases of PCVS, the diagnosis is mainly based upon your history, symptoms and examination. In many instances, he will order appropriate tests before he sees you to streamline your management and avoid unnecessary appointments. These tests are bulk-billed. The most common tests to assist the diagnosis of PCVS may be a specialised abdominal and leg vascular ultrasound and in some cases a CT scan. In very rare cases an MRI scan may be arranged but normally only after seeing Dr Ponosh.

Based upon Dr Ponosh’s expert review, an appropriate treatment plan will be suggested and explained to you in an open, straight-forward, jargon-free manner with all options and questions addressed.

Pelvic or abdominal pain can be a common symptom, often persisting for over 6 months duration. The pain is usually on one side but can affect both sides. The pain is worse on standing, lifting, when you are tired, during pregnancy and during or after sexual intercourse. The veins are also affected by the menstrual cycle/hormones and therefore the pain can increase during the time of menstruation. The pain usually is improved by lying down.

PCVS is a significant and common cause of complicated and unusual leg vein issues.

The Definitive Test – Abdominal Venogram

Although ultrasound, CT and MRI may be initially used, PCVS is notoriously difficult to diagnose on imaging and in many cases is not clearly defined. This is not a failure of the test but is a reflection of the challenging and difficult assessment of the presence and function of these veins.

Even if the imaging does not clearly show evidence of PCVS, if Dr Ponosh suspects its presence from his vast clinical experience, he may recommend an Abdominal Venogram.

This is a low risk, minimally invasive procedure usually conducted as a day case in hospital under local anaesthetic and light sedation so is essentially pain free (please refer to angiogram and venogram information). In a specialised x-ray room, a small needle is placed in your groin and under x-ray guided imaging and through the injection of contrast dye, the nature of your abdominal veins and any evidence of PCVS is identified. This may appear as varicose veins in your pelvis, dilated ovarian or pelvic veins or in some cases compression of other draining veins. You will be asked to hold your breath several times and occasionally a special CT scan may be taken during your procedure (Dyna CT) for a very detailed assessment.

Incompetent left ovarian vein filling pelvic varicose veins shown on a venogram.

If PCVS is confirmed, usually through the identification of a dilated ovarian vein, Dr Ponosh will proceed to definitively treat this during the same procedure. The malfunctioning vein (usually the left but in some cases the right or both) is entered with a fine wire and tube (1 mm in size) and the vein is permanently blocked off with tiny coils in a controlled and planned fashion. This is known as “coil embolisation”. The treatment of these dilated veins stops the blood pooling in the pelvis and stops the venous congestion and hypertension that causes your symptoms.

Embolized left ovarian veins on venogram.

The venogram takes approximately 20 minutes and, if found, the “coil embolisation” takes an additional 10 minutes. The benefit of this procedure is that it is definitive. It is the only way of conclusively confirming or excluding PCVS and treating it in the same procedure. In rare instances where PCVS is not found, there is still significant clinical benefit as it definitively rules out the condition. If it is present, it is easily treated. Apart from being extremely low risk and minimally invasive, it has a rapid recovery.

In cases of May-Thurner Syndrome, a venogram is also undertaken, but if found, it is usually treated with a balloon venoplasty (stretching the vein) or placing a stent to permanently treat the narrowing. Dr Ponosh will discuss this further with you if suspected.

Dr Ponosh is a no gap provider, so there is no cost for this procedure for all private health funds.

Following the procedure, some gentle pressure is applied to your groin. You rest in bed for approximately 3 hours and you in almost all instances are home later in the day. Dr Ponosh recommends a quiet day or two at home, but the procedure has little impact on your day to day life.

What are the benefits and risks of the Ovarian Vein Embolisation?

Benefits

  • Pelvic vein/ovarian vein embolisation has been shown to be a safe procedure with relief of the symptoms of pain, and improvement in the appearances of the varicose veins.
  • Embolisation is a highly effective way of blocking the vessel.
  • Minimally invasive
  • Essentially pain free procedure
  • A majority of women (up to 85%) find they have an improvement within 2 weeks of the procedure.
  • Rapid recovery

Risks

  • There is a very slight risk of an allergic reaction if contrast is injected.
  • There is an extremely small risk of infection after ovarian vein embolisation
  • Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessels, bruising or bleeding at the puncture site.
      • In extremely rare cases this may need surgical repair
  • There is a small chance that embolisation coils deploy in the wrong place (this is called non-target embolisation). It is extremely rare and in Dr Ponosh’s vast experience, he has never seen it.
  • Recurrence of the varicose veins can occur in up to 5%.
  • The commonest complaint is a day or two of pelvic pain or back pain as the treated vein blocks off (called ovarian vein thrombophlebitis). This is treated with simple pain killers and is self limiting.

What happens after the procedure?

Pain following the procedure is usually minimal. A dull ache in the groin is not uncommon and well controlled with paracetamol. Following the procedure, bed rest is required for a short time and most people leave the hospital within 4 hours of the procedure.

Once discharged, you are able to resume your normal activities within the first 24-48 hours. The best advice is not to overexert yourself and avoid heavy lifting or strenuous gym work for 5-7 days.

Some people may develop an aching back or loin pain, similar to period pain for a few days following the procedure as the embolised veins completely block off. This resolves rapidly and is well controlled with regular oral pain medications.

By treating your PCVS, the pelvic varicose veins should gradually shrink away over a few weeks and your symptoms improve. As the main ovarian and pelvic veins have been embolised, if you also have any lower leg varices, these can now be treated with a reduced chance of them coming back in the future (which they have a high chance of coming back if you did not have the pelvic vein embolisation). Dr Ponosh will discuss your leg vein management in detail with you. Any symptoms that you have been having related to the varicose veins in the pelvis should also slowly improve.