DISCUSSION
The CT shows several enhancing serpentine structures (arrow) in the pelvic cavity on each side of the uterus. These structures represent varicose veins in the pelvic cavity. These can contribute to a condition known as pelvic congestion syndrome (PCS).
PCS is an often overlooked diagnosis in the evaluation of women with chronic pelvic pain. Sometimes such women receive a wrong diagnosis of depression. Although the etiology of PCS is unknown, anatomic or hormonal abnormalities are thought to play a role. PCS should be considered if pelvic pain persists after other causes, including infection, bowel disease, endometriosis, and fibroids, are eliminated.
Typically, a patient with PCS will be of childbearing age and multiparous. Symptoms include low backache, tenderness of the ovaries, frequent urination, postcoital pain, abnormal menses, and vaginal discharge. The patient may report that her symptoms worsen before or during menses, when standing, during or after intercourse, or during pregnancy. PCS can also be associated with a retroverted uterus, polycystic ovaries, and fullness of the legs. It should also be noted that not all patients with dilated pelvic veins have symptoms. On physical examination, there may be ovarian tenderness. Varicosities may also be seen on the thighs or labia. The cervix can have a blue coloration due to venous congestion.
The veins of the pelvis can be evaluated using many methods. These include venography, sonography, CT, MRI, and sometimes laparoscopy. Venography is considered the most accurate method, but it also carries more risks because of its invasiveness.
Sonography or cross-sectional imaging is more commonly performed first, especially if other diagnoses are still being considered, as these modalities also visualize surrounding anatomy. Sonography may show thickening of the endometrium and increased volume of the ovaries, which can be associated with PCS. Sonography can also show anechoic structures that are linear or serpiginous, measure more than 5 mm in diameter, and are located on either side of the uterus and cervix (compatible with dilated pelvic veins). These veins should increase in diameter with standing or with the Valsalva's maneuver. The sonogram for the patient in this case had normal findings.
MRI and CT may show dilated veins in the pelvis. CT is not generally used to obtain a detailed view of the pelvic organs, so the finding of dilated pelvic veins may be incidental if the test was ordered for other reasons. MRI may show uterine abnormalities, such as fibroids or adenomyosis. Laparoscopy can visualize varicosities in the pelvis if the patient is placed in reverse Trendelenburg's position and the intra-abdominal pressure is decreased (to allow filling of the veins).
Treatment of PCS is directed toward alleviation of symptoms, so treatment is not necessary if the patient is asymptomatic. Medications—including vasoconstrictors and drugs to suppress ovarian function
—are sometimes used but may give only short-term relief. Surgical options include removal or ligation of the veins, uterine ventrosuspension (if the uterus is retroverted), or hysterectomy with bilateral oophorectomy (usually performed only as a last resort).
Venous embolization is another option and is generally performed by an interventional radiologist. During this minimally invasive procedure, a small catheter is used, approaching from the groin region, to access the ovarian veins. Venography is utilized to demonstrate the varicosities. Then, using fluoroscopy, the radiologist performs selective embolization of the veins. This can be done with stainless steel coils, absorbable sponges, or liquids made specifically for embolization. This procedure has been reported to provide significant relief in more than 70% of symptomatic patients. Sometimes embolization may have to be repeated to obtain better results.
Figure 2 shows the embolization coils used to occlude this patient's ovarian veins. Her symptoms improved significantly after treatment. JAAPA
The author practices in a radiology group at North Oaks Health System, Hammond, La. She has indicated no relationships to disclose relating to the content of this article.