Article

Pelvic congestion syndrome: Does one name fit all?

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  • Nuova Villa Claudia, Rome, Italy
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Abstract

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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... Seven PELVs have been described, connecting the pelvic veins to the veins of the genital region and/or lower extremity. The most common are pudendal PELVs, which are found in 60-70% of women with VVs of pelvic origin [10,11]. Pudendal PELVs relate to the internal pudendal vein, which runs in the pudendal canal (Alcock's canal) along the inferior ischial ramus. ...
... The second most common PELV is the inguinal PELV, which is diagnosed in 21-36% of patients with VVs of pelvic origin [10,11]. Reflux from the pelvic veins is transmitted through the inguinal canal via the round ligament vein and may be responsible for VVs at the mons pubis, vulva, and lower limb. ...
... There are two gluteal PELVs: inferior and superior PELVs. The inferior gluteal PELV is the cause of VVs of pelvic origin in 3.7% of patients [11]. The inferior gluteal vein enters the pelvis through the greater sciatic foramen, below the piriformis muscle. ...
Article
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Varicose veins (VVs) of pelvic origin are one of the clinical presentations of pelvic venous disorders (PeVD) and are increasingly being diagnosed in patients in phlebological offices these days. To investigate VVs potentially resulting from pelvic vein incompetence (PVI), a usual full duplex ultrasonography (DUS) of lower extremity veins in the upright position is recommended as well as DUS for evaluation of pelvic escape points (PELVs). Seven PELVs have been described, connecting the pelvic veins to the veins of the genital region and/or legs. There are two possible treatment options for pelvic origin VVs, top-down treatment such as pelvic vein embolization or treatment of iliac/renal vein compression if it is the cause of PVI and bottom-up treatment of PELVs and related VVs. The idea of the latter approach is to treat the causes of the external pelvic VVs in the genital region and VVs in the legs without having to treat asymptomatic pelvic veins within the pelvis. The most common methods of bottom- up treatment are sclerotherapy, surgical ligation and miniphlebectomy. The efficacy of such treatment approach for VVs of pelvic origin has been reported in the literature, whereas studies have failed to demonstrate good results of top- down treatment in the context of eliminating VVs of pelvic origin as well as minimizing the risk of VVs recurrence. Bottom-up treatment is a useful option to avoid unnecessary and more expensive pelvic vein embolization and should be considered as an initial therapeutic approach. Only if bottom-up treatment fails, if the VVs recur rapidly, or if the patient develops pelvic symptoms due to PVI, pelvic veins embolization can be considered.
... 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. ...
... Pelvic venous disorder as pain cause is becoming more and more recognized in the global medical community. Nevertheless, the different possible involvement of the lower limb venous circulation by means of pelvic escape points depicts a heterogenous scenario that can still generate uncertainty on the best possible management [3]. ...
... Interestingly VAS significantly diminished both in the group with and without reflux suppression (from 3.4+0.7 to 0.8+0.3 and from 3.6+0.7 to 2.1+1 (p<.05), respectively). This finding points out once again how the indication to pelvic venous disorder treatment must focus on the clinical data together with the instrumental diagnostic assessment, rather than just on the report of a dilation and/or of a reflux [3]. ...
Article
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Pelvic venous disorder represents an as common as challenging clinical scenario because of the blurred borders between pelvic region and lower limb treatment target, because of the subtle and aspecific signs and symptoms, because of the lack of large randomized comparative trials providing clarity on the best practice and strong recommendations. Herein we present pathophysiology and clinical considerations on the lower limb varicosities of pelvic origin, suggesting possible management strategies based on clinical manifestation, ultrasound detection and targeted sclerotherapy. Large studies are needed to identify the best diagnostic parameters guiding the best strategy and highlighting the most reliable reported outcomes from such heterogeneous patients.
... 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. ...
... The implementation of individualized treatment strategies for leak points will result in a reduction in unnecessary interventions while simultaneously maintaining the functionality of normal great saphenous vein branches. In a large-scale study of 985 women [26], 76.8% of patients identified lower-limb varicose veins caused by pelvic escape points and showed symptomatic improvement by point (perineal point: 70.8%, inguinal point: 20.7%, inferior gluteal point: 3.7%, obturator point: 3.2%, superior gluteal point: 1.6%). Echo-guided direct foam sclerotherapy and venous reflux in the pelvic region showed an improvement of symptoms by treatment through secondlevel imaging, and it was found that if the study had been conducted with a detailed classification of leaking points, it could have been very helpful in preserving the normal function of the great saphenous vein, and it may be a limitation of this study, which was conducted retrospectively. ...
Article
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Objective: The purpose of this study was to evaluate the incidence of gonadal vein refluxes associated with lower-extremity varicose veins with Doppler ultrasonography (DUS). Method: A total of 6279 patients with venous disease-related symptoms of the lower extremity were evaluated with DUS in the vascular lab. Gonadal vein reflux using abdominal ultrasound was further evaluated in patients with unusual varices, defined as varices in the inguinal, inner or upper thigh and the vulvar area without refluxes in the saphenofemoral junction (SPJ). Those patients who showed gonadal vein reflux were diagnosed as having pelvic-origin varicosity. Results: Unusual varices were found in a total of 237 patients (3.8%), and of these patients, pelvic-origin varicosity was discovered with transabdominal ultrasound in 156 (65.8%). A total of 66.7% (n = 38/57) of unusual varix patients with pelvic pain had gonadal vein reflux. The measurement of gonadal vein diameter was larger in ultrasonography than CT scans (8.835 vs. 8.81, p < 0.001). Two patients with severe symptoms but no obstructive venous diseases were treated with gonadal vein embolization. Conclusion: The incidence of pelvic-origin varicosities was 2.5% (n = 156/6279). However, more than half of the patients with unusual varices had gonadal vein reflux and 24.4% of these patients also presented with pelvic pain. The evaluation of pelvic-origin varicosities should be performed in patients who present with unusual forms of varices of the lower extremity.
... 56 Venous hypertension and the related inflammation can be partially compensated by the perineal leaking points, downloading the pressure on the lower limb varicose veins. 166 The hormonal status can influence the symptomatology that usually resolve after menopause: a finding that indirectly could suggest the same hormones role in vein dilation. Indeed, estrogen leads to nitric oxide secretion, resulting in increased dilatation and vein wall deterioration. ...
Article
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Published scientific evidence demonstrate the current spread of healthcare misinformation in the most popular social networks and unofficial communication channels. Up to 40% of the medical websites were identified reporting inappropriate information, moreover being shared more than 450,000 times in a 5-year-time frame. The phenomenon is particularly spread in infective diseases medicine, oncology and cardiovascular medicine. The present document is the result of a scientific and educational endeavor by a worldwide group of top experts who selected and analyzed the major issues and related evidence-based facts on vein and lymphatic management. A section of this work is entirely dedicated to the patients and therefore written in layman terms, with the aim of improving public vein-lymphatic awareness. The part dedicated to the medical professionals includes a revision of the current literature, summing up the statements that are fully evidence-based in venous and lymphatic disease management, and suggesting future lines of research to fulfill the still unmet needs. The document has been written following an intense digital interaction among dedicated working groups, leading to an institutional project presentation during the Universal Expo in Dubai, in the occasion of the v-WINter 2022 meeting.
... 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]. ...
Article
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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.
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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.
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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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