E1819. Pelvic Congestion Syndrome: A Guide to Imaging and Management
Chronic pelvic pain is defined as either intermittent or constant non-cyclical pain localized to the pelvis, lasting for a duration of at least 6 months. Approximately 10% of all gynecology referrals are due to chronic pelvic pain. Additionally, in 30% of patients with chronic pelvic pain, pelvic congestion syndrome (PCS) was identified as the only cause of their pain. PCS is a common cause of chronic pelvic pain that is not well understood, and as a result, often misdiagnosed. PCS is the clinical manifestation of pelvic venous insufficiency, which is a result of the incompetence of the gonadal veins, internal iliac veins, or both. This results in retrograde flow that can produce pelvic, vulvar, and/or perineal varicosities. Patients often present with pelvic pain or discomfort that results in significant functional impairment. The diagnosis of PCS can be made using multiple forms of noninvasive imaging including ultrasound, CT, or MRV, as well as through invasive imaging like pelvic venous angiography. The definitive treatment is pelvic vein embolization, which is both well tolerated and highly effective in resolving symptoms.
Educational Goals / Teaching Points
The target audience for this educational exhibit are trainees in the field of interventional radiology. The goals include reviewing the clinical presentation of PCS, and the role of noninvasive and invasive imaging in the diagnosis of pelvic venous insufficiency. We will also discuss the management options. Most importantly, we will be discussing the role of interventional radiology in the treatment of pelvic congestion syndrome.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
We will review the normal anatomy of the venous drainage of the pelvis, and discuss common variants including narrowing of the distal segment of the left renal vein, nutcracker syndrome (extrinsic compression of the left renal vein by the SMA), and atypical drainage of the right gonadal vein into the right renal vein. We will discuss the diagnostic imaging criteria for pelvic venous insufficiency on transabdominal and transvaginal ultrasound, CT, and MRV. Lastly, we will review the procedural steps of pelvic vein embolization.
PCS is a commonly overlooked cause of chronic pelvic pain, resulting in functional impairment in many patients, particularly women of childbearing age. It is important to be aware of the multitude of imaging findings that can help identify pelvic venous insufficiency, thus making the diagnosis of pelvic congestion syndrome. If properly identified, pelvic vein embolization has been found to be an effective, well-tolerated method of resolving symptoms and improving functional status.