Pelvic congestion syndrome: Does one name fit all?

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The pelvic congestion syndrome definition includes two not so frequently overlapping scenarios: (i) pelvic venous engorgement with lower abdomen symptomatology; and (ii) lower limb varicose veins fed by pelvic escape points that are generally less prone to develop the abdominal clinical manifestation typical for pelvic congestion syndrome. We retrospectively evaluated 985 female patients (43±11 years old; 23±5kg/m² BMI) who visited our offices for lower limb varicose veins of pelvic origin. Second-level imaging was needed for 229 patients. The remaining 756 patients underwent direct echo-guided foam sclerotherapy in proximity of the pelvic escape points. At a mean follow-up of 4.1±1.4 years, 595 patients were successfully treated. Among the successfully treated group, mild lower abdomen heaviness and occasional dyspareunia was reported by 14 and 11 women, respectively, prior to the injection. At the end of the follow up, a significant reduction in the symptomatology was reported for both lower abdomen heaviness and dyspareunia. In traditional pelvic congestion syndrome, an accurate diagnosis protocol eventually ends in an interventional radiology suite. Conversely, in cases of lower limb varicose veins of pelvic origin, the phlebologist can, and in our opinion should, assume a pivotal role both in the diagnostic and therapeutic part.

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... An ovarian vein diameter of 6 mm on transabdominal ultrasonography has been reported to have a 96% positive predictive value for pelvic varices; although diameter measurements alone do not correlate well with ovarian vein reflux and so the examination should also look for reflux with the patient in a 45° position. [5][6][7][8][9] Transvaginal ultrasound is considered to be the examination of choice because it offers better visualization of the pelvic venous plexus compared to transabdominal ultrasound. The presence of circular or linear venous structures with a diameter >5 mm is indicative of pelvic varicosities. ...
... Furthermore, the renal veins can be assessed for signs of compression (Nutcracker syndrome), as well as the common and/or external iliac vein. [7][8][9] Catheter-directed retrograde selective venography of ovarian and internal iliac veins is a method of choice for the diagnosis of pelvic venous pathology. [4][5][6] Usage of intravascular ultrasound for the diagnosis of PCS is very rare and mostly performed for detecting compressive syndromes (Nutcracker and May-Thurner syndrome) or in postthrombotic damage of the veins. ...
... laparoscopy include existence of prominent enlarged broad ligament veins and may reveal pelvic varices. [2,5,8] For the confirmation of diagnosis of PCS, other pathologies of the pelvis must be excluded, such as fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, ovarian, and Fallopian tube diseases, pelvic tumors, cystitis, inflammatory bowel diseases and adhesions, pelvic arterial venous malformations, and portal hypertension. ...
... 14 Other clinical manifestations of pelvic congestion syndrome may be various and it can be shown as a symptoms of different systems: gynecological (dysmenorrhea, vaginal discharge), urological (disuria, urinary frequency), gastroenterological (nausea, bloating, abdominal cramps, rectal discomfort). 33 More seldom a patient with pelvic varicosities may present with renal colics, due to ureteral compression by a dilated ovarian vein. This is known as "ovarian vein syndrome". ...
... 10 Since then, many authors have used this procedure, with positive results in most patients. 33, 60, 66-73 The aim of emdisorders these will be the gonadal axes, pelvic varicose iliac veins. ...
... 14 O zamandan beri bu prosedür birçok hastada olumlu sonuçlar ile kullanılmıştır. [10][11][12]14,[17][18][19][20][21][22] Embolizasyonun amacı yetersizlik olan venöz aksları reflünün orijinine mümkün olan en yakın yerden oklüde etmektir. Pelvik venöz hastalıklarda bunlar gonadal aks, pelvik variköz venler ve internal iliak venin yetersizlik olan dallarıdır. ...
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ZET Pelvik Konjesyon Sendromu için tedavi seçenekleri tartışmalı tanı yöntemleri ve psikosomatik orijinden vasküler nedenlere kadar değişen etiyolojinin iyi anlaşılamaması nedeniyle yakın zamana kadar belirsiz kalmıştır. Semptomatik (ağrı kesici) tedaviyi analjezikler, nonsteroid antiinflamatuvar ilaçlar, psi-kotropik ilaçlar oluşturur. Bu tedaviler geçici etki sağlar. Hormonal tedavinin (medroksiprogesteron ase-tat-MPA, gonadotropin salıcı hormon GnRH) terapötik etkisi vardır. Ancak uzun dönem kullanımı artmış osteoporoz riski nedeniyle önerilmez. MPFF (Mikronize saflaştırılmış flavonoid fraksiyonu) pelvik kon-jesyon sendromlu hastalarda pelvik dolaşımda venöz tonusu sağlar. Ağrı, ağırlık hissi gibi pelvik semp-tomları rahatlatır. MPFF bu hastalarda iyi bir seçenektir. Güncel cerrahi tedavi açık ya da laparoskopik cerrahi ile yetmezlik olan venlerin ligasyonudur. Ancak bu prosedürler endovasküler embolizasyondan daha invazivdir, nadiren uygulanır ve genel anestezi gerektirir. Reprodüktif organların cerrahisi tedavi olarak önerilmemektedir. Perineal, vulvar, gluteal ya da posterior uyluk lokalizasyonundaki atipik vari-köz venlerin tedavisinde gonadal venlere köpük enjeksiyonu ya da likit sklerozan enjeksiyonu yapılır. Transkatater embolizasyon tedavisi pelvik konjesyon sendromunda tercih edilen tedavilerdendir. Em-bolizasyonun amacı Yetmezlik olan veni kaçağın orijinine mümkün olan en yakın yerden oklüde et-mektedir. Bunlar pelvik venöz hastalıklarda gonadal ven, pelvik variköz ven ve internal iliak venin yetmezlik olan dallarıdır. Venöz kompresif sendromlar pelvik venöz hipertansiyona neden olabilir. Ana iliak veni ya da sol renal veni stentlemek iyi bir tedavi seçeneği olabilir. Ancak stentlerin etkisini de-ğerlendirmek için randomize kontrollü çalışmalara ihtiyaç vardır. Pelvik konjesyon sendromunda gün-cel tedavi seçeneği obstrüksiyon yokluğunda pelvik ven embolizasyonudur. Bu tip tedaviler sonrası komplikasyonlar çok nadirdir. Anah tar Ke li me ler: Pelvik ağrı; variköz venler ABS TRACT Treatment options for pelvic congestion syndrome remained uncertain until recently due to controversial diagnostic methods and the etiology ranging from psychosomatic origin to vascular causes.Symptomatic (pain-relief) therapy include analgesics, nonsteroidal anti-inflammatory drugs, psy-chotropic drugs, but the effect of such therapy is transient. Hormonal therapy (medoxyprogesterone acetate MPA, gonadotropin-releasing hormone GnRH) seems to have therapeutic effect, but long-term usage is not recommended because of the high risk of osteoporosis.Early enhancement of venous tone with MPFF may restore pelvic circulation for patients with PCS; by relieving pelvic symptoms, such as pain and heaviness, MPFF represents therefore an option for these patients. Current surgical treatment includes open or laparoscopic surgery to ligate the insufficient veins. However, these procedures are rarely performed as they are more invasive than endovascular embolization procedures, and require a general anesthetic and a longer recovery period. Surgery of the reproductive organs is not advised as a treatment option. Injecting foam or liquid sclerosant could be used for occlusion of truncal (gonadal) veins and for the treatment of atypical varicose veins of perineal, vulval, gluteal or posterior thigh localiza-tion. Transcatheter embolization therapy is the method of choice for the treatment of PCS. The aim of embolization is to occlude insufficient venous axes as close as possible to the origin of the leak. In pelvic venous disorders these will be the gonadal axes, pelvic varicose veins and insufficient tributary branches of the internal iliac veins. However, published evidence of its effect has been criticized for the lack of validated clinical and imaging criteria for the disorders responsible for pelvic venous disease. Venous compressive syndromes could also lead to pelvic venous plexus hypertension and result in PCS. Stenting the common iliac vein or left renal vein could be a good treatment option. However, ran-domized controlled trials assessing the effect of stenting are needed. Treatment of choice for PCS currently is pelvic vein embolization, in the absence of obstructions. Serious complications after this kind of treatment are very rare.
... A velocity ratio > 5 is indicative of significant stenosis. It is also important to visualize the flow direction of the left internal iliac vein (normal or reversed) [14,15]. ...
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Sex hormonal direct action on venous system has been advocated for explaining further dilatation of already present limb varices, or stimulate recurrences after varicose veins removal, or even dilate normal veins inducing valves incompetence, typically in women, but also in men. Hormones can directly reach leg vein trough Pelvic Veins Incontinence. This event is frequent and quite well evidenced by Ultrasound or Radiology. Blood sampling of hormones from antecubital vein (as a control) compared with blood from varicose veins could more easily (and less costly) make possible to evidence this hormonal discrepancy whose ratio could become the index of this hormonal influence and, indirectly, pelvic reflux. Many clinical situations could benefit from this study, which may provide reasons for taking a less aggressive approach, for directing attention to leaking points and the identification of cases at risk of recurrences, suggesting a regular use of compression stockings.
Pelvic veins incompetence may cause varicose veins formation in the lower extremity due to leak points of the pelvic circulation. This observation is particularly frequent in recurrence cases especially in multi parity. The cause of pelvic vein dilatation is still not clear. Traditional mechanism for varicose veins formation referred to leg varices cannot be transferred to pelvic circulation where a strong efficient pumping mechanism and a high hydrostatic column is missing. An alternative explanation is possible if hormonal factors are considered to contribute to vasodilatation (estrogen is a potent vasodilator), and pelvic veins are naturally exposed to high doses of ovarian hormones. Pelvic veins dilatation/hypertension , rich in estrogens, may be directed through leak points to leg veins where estrogens effect of vasodilation is maintained. Then, at every Valsalva like action, some blood rich in estrogens passes in the leg network giving rise, among others, to perineal veins dilatation, recurrence after groin dissection for SFJ high ligation, intermittent leg pain/discomfort. Estrogens sampling studies could confirm this hypothesis and guide alternative treatments.
The causes of chronic pelvic pain (CPP) in women can be multifactorial and significantly affect quality of life. Finding the cause(s) for CPP often takes a multidisciplinary approach. One commonly overlooked cause of CPP is pelvic venous disease (PVD). The causal relationship between PVD and CPP has been well-documented in the literature, but with limited assessment or treatment guidelines to advise health care providers, there continues to be a limited understanding of PVD. This article aims to ensure nurse practitioners are well equipped to recognize women presenting with symptoms suggestive of PVD and expedite referral when needed for further evaluation.
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