Pelvic venous disorders (PeVD) is a comprehensive term that describes a spectrum of symptoms and signs arising from pelvic venous system dysfunction due to venous obstruction (thrombotic or nonthrombotic) or venous reflux (1). This term replaced several previous terms, including pelvic congestion syndrome, May-Thurner syndrome, and nutcracker syndrome. PeVD are classified according to the Symptoms-Varices-Pathophysiology system (2).
Although pelvic venous anatomic variations are common and often asymptomatic, they may also be associated with pelvic pain or other symptoms.
The prevalence of PeVD is uncertain, but it appears to be more common in premenopausal than in postmenopausal women (3).
General reference
1. Knuttinen MG, Machan L, Khilnani NM, et al. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2023;221(5):565-574. doi:10.2214/AJR.22.28796
2. Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568-584. doi:10.1016/j.jvsv.2020.12.084
3. Jurga-Karwacka A, Karwacki GM, Schoetzau A, Zech CJ, Heinzelmann-Schwarz V, Schwab FD. A forgotten disease: Pelvic congestion syndrome as a cause of chronic lower abdominal pain. PLoS One. 2019;14(4):e0213834. Published 2019 Apr 2. doi:10.1371/journal.pone.0213834
Symptoms and Signs of Pelvic Venous Disorders
Chronic pelvic pain is a common symptom of pelvic venous disorders. Typically, the pain is a dull ache, but it may be sharp or throbbing. The pain tends to be unilateral but may be bilateral. It is worse after prolonged standing, walking, or other activities that increase intra-abominal pressure and is relieved by lying down (1).
Postcoital ache (prolonged pain after intercourse) and deep dyspareunia are also frequently reported.
Other symptoms include pelvic heaviness or pressure, dysmenorrhea, and increased vaginal discharge.
If venous obstruction is present, symptoms may also include left flank or abdominal pain, microscopic hematuria or gross hematuria, and, less commonly, venous claudication or lower extremity swelling.
Women may also have visible or palpable varicose veins in the vulva, perineum, or lower extremities. Focal adnexal tenderness may be present on bimanual pelvic examination.
Symptoms and signs reference
1. Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568-584. doi:10.1016/j.jvsv.2020.12.084
Diagnosis of Pelvic Venous Disorders
Pelvic imaging to detect ovarian varicosities
Diagnosis of pelvic venous disorders is based on the presence of characteristic symptoms (chronic pelvic pain with prolonged standing or postcoitally) for > 6 months, with ovarian tenderness on pelvic examination.
Pelvic ultrasound is often the initial imaging study. It may not show varicosities while patients are recumbent. It is also performed to exclude other etiologies of chronic pelvic pain.
Some experts recommend additional tests (eg, transabdominal ultrasound, CT, MRI, catheter venography, intravascular ultrasound) if necessary to confirm pelvic varicosities (1). Pelvic varicosities may be confirmed by selectively catheterizing specific veins and injecting a contrast agent (venography).
If pelvic pain is bothersome and persistent and the cause has not been identified, laparoscopy may be performed. However laparoscopy may not detect ovarian vein varicosities due to the use of Trendelenburg position and compression by CO2 pressure.
Diagnosis reference
1. Knuttinen MG, Machan L, Khilnani NM, et al. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2023;221(5):565-574. doi:10.2214/AJR.22.28796
Treatment of Pelvic Venous Disorders
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Compression shorts
High-quality evidence about treatment options for PeVD is lacking.
Conservative measures include NSAIDs, and some experts advise use of compression shorts, but not compression stockings.
If conservative measures are ineffective and the pain persists and is severe, treatment depends on the pathophysiology.
For venous reflux (eg, due to incompetent ovarian or internal iliac veins), minimally invasive endovascular embolization may be considered; however, symptoms may return from other tributaries and postembolization syndrome may occur (1, 2). Varicosities detected during venography may be embolized with small coils or an embolic agent after local anesthesia and IV sedation are used. This procedure reduces the need for analgesics by up to 80%; complications include groin hematoma, coil migration, and reaction to contrast media (3).
For venous obstruction, treatments include endovascular stenting and balloon angioplasty.
Surgery (eg, ovarian vein ligation or excision) may be considered if minimally invasive procedures are unsuccessful.
Treatment references
1. Bałabuszek K, Toborek M, Pietura R. Comprehensive overview of the venous disorder known as pelvic congestion syndrome. Ann Med. 2022;54(1):22-36. doi:10.1080/07853890.2021.2014556
2. Knuttinen MG, Machan L, Khilnani NM, et al. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2023;221(5):565-574. doi:10.2214/AJR.22.28796
2. Laborda A, Medrano J, de Blas I, Urtiaga I, Carnevale FC, de Gregorio MA. Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 2013;36(4):1006-1014. doi:10.1007/s00270-013-0586-2
Guidelines for Pelvic Venous Disorders
The following is a list of professional medical society or government clinical practice guidelines regarding this medical issue (this is not a comprehensive list):
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin. Chronic Pelvic Pain. 2020 (reaffirmed 2023).
Key Points
Pelvic venous disorders (PeVD) are defined as symptoms and signs arising from pelvic venous obstruction or reflux.
PeVD occurs most frequently in premenopausal women.
Pain is usually worsened by standing and by sexual intercourse; other symptoms include pelvic heaviness or pressure, dysmenorrhea, increased vaginal discharge, left flank or abdominal pain, microscopic hematuria or gross hematuria, and, less commonly, venous claudication or lower extremity swelling.
Physical examination findings may include visible or palpable varicose veins in the vulva, perineum, or lower extremities or focal adnexal tenderness on pelvic examination.
Positive imaging alone is nondiagnostic, because many women with ovarian vein varicosities are asymptomatic; do not treat an isolated finding of dilated pelvic veins.
Treat with NSAIDs or compression shorts.
If pain persists and is severe, consider endovascular embolization, endovascular stenting, or balloon angioplasty; consider surgery (vein ligation or excision) if minimally invasive procedures are unsuccessful.
