Semin intervent Radiol 2023; 40(04): 362-371
DOI: 10.1055/s-0043-1771041
Review Article

Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment

Meghan R. Clark
1   Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
,
Amy C. Taylor
1   Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Pelvic venous disorder (PeVD) is a term that encompasses all the interrelated causes of chronic pelvic pain (CPP) and perineal/lower extremity varicose veins of pelvic venous origin historically known as nutcracker syndrome, pelvic congestion syndrome, and May-Thurner syndrome, resulting in a more precise diagnosis that accounts for the underlying pathophysiology and anatomy. PeVD manifests as CPP with associated vulvar and lower-extremity varicosities, left flank pain and hematuria, and lower extremity pain and swelling secondary to obstruction or reflux in the left renal, ovarian, or iliac veins. This article will focus specifically on the most current nomenclature, evaluation, and management of CPP of venous origin.

Keywords

pelvic venous disease - pelvic pain - embolization - sclerotherapy - interventional radiology - women's health


Publication History

Article published online:
10 August 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Chronic pelvic pain: ACOG Practice Bulletin, number 218. Obstet Gynecol 2020; 135 (03) e98-e109
    CrossrefPubMedGoogle Scholar
  • 2 Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996; 87 (03) 321-327
    CrossrefPubMedGoogle Scholar
  • 3 Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician 2014; 17 (02) E141-E147
    CrossrefPubMedGoogle Scholar
  • 4 Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic pelvic pain in women: a review. JAMA 2021; 325 (23) 2381-2391
    CrossrefPubMedGoogle Scholar
  • 5 Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monit 2008; 14 (01) CR24-CR31
    PubMedGoogle Scholar
  • 6 Howard FM. The role of laparoscopy in the evaluation of chronic pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc Gynecol Laparosc 1996; 4 (01) 85-94
    CrossrefPubMedGoogle Scholar
  • 7 Tirlapur SA, Daniels JP, Khan KS. MEDAL Trial Collaboration. Chronic pelvic pain: how does noninvasive imaging compare with diagnostic laparoscopy?. Curr Opin Obstet Gynecol 2015; 27 (06) 445-448
    CrossrefPubMedGoogle Scholar
  • 8 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 (03) 568-584
    CrossrefPubMedGoogle Scholar
  • 9 Lurie F, Passman M, Meisner M. et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord 2020; 8 (03) 342-352
    CrossrefPubMedGoogle Scholar
  • 10 Topper SR, Winokur RS. Imaging of pelvic venous disorders (PeVD); Should every patient get an MRI?. Tech Vasc Interv Radiol 2021; 24 (01) 100731
    CrossrefPubMedGoogle Scholar
  • 11 Khilnani NM, Meissner MH, Learman LA. et al. Research priorities in pelvic venous disorders in women: recommendations from a multidisciplinary research consensus panel. J Vasc Interv Radiol 2019; 30 (06) 781-789
    CrossrefPubMedGoogle Scholar
  • 12 Khilnani NM, Winokur RS, Scherer KL, Meissner MH. Clinical presentation and evaluation of pelvic venous disorders in women. Tech Vasc Interv Radiol 2021; 24 (01) 100730
    CrossrefPubMedGoogle Scholar
  • 13 Maratto S, Khilnani NM, Winokur RS. Clinical Presentation, Patient Assessment, Anatomy, Pathophysiology, and Imaging of Pelvic Venous Disease. Thieme Medical Publishers, Inc.; 2021: 233-238
    Google Scholar
  • 14 Asciutto G, Mumme A, Asciutto KC, Geier B. Oestradiol levels in varicose vein blood of patients with and without pelvic vein incompetence (PVI): diagnostic implications. Eur J Vasc Endovasc Surg 2010; 40 (01) 117-121
    CrossrefPubMedGoogle Scholar
  • 15 Ignacio EA, Dua R, Sarin S. et al. Pelvic Congestion Syndrome: Diagnosis and Treatment. Thieme Medical Publishers; 2008: 361-368
    Google Scholar
  • 16 Durham JD, Machan L. Pelvic Congestion Syndrome. Thieme Medical Publishers; 2013: 372-380
    Google Scholar
  • 17 Gibson K, Minjarez R, Ferris B. et al. Clinical presentation of women with pelvic source varicose veins in the perineum as a first step in the development of a disease-specific patient assessment tool. J Vasc Surg Venous Lymphat Disord 2017; 5 (04) 493-499
    CrossrefPubMedGoogle Scholar
  • 18 Ford RW, Winokur RS. Pelvic Venous Disorders (PeVD). Thieme Medical Publishers, Inc.; 2022: 483-489
    Google Scholar
  • 19 Herrera-Betancourt AL, Villegas-Echeverri JD, López-Jaramillo JD, López-Isanoa JD, Estrada-Alvarez JM. Sensitivity and specificity of clinical findings for the diagnosis of pelvic congestion syndrome in women with chronic pelvic pain. Phlebology 2018; 33 (05) 303-308
    CrossrefPubMedGoogle Scholar
  • 20 Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984; 2 (8409): 946-949
    CrossrefPubMedGoogle Scholar
  • 21 Yang DM, Kim HC, Nam DH, Jahng GH, Huh CY, Lim JW. Time-resolved MR angiography for detecting and grading ovarian venous reflux: comparison with conventional venography. Br J Radiol 2012; 85 (1014): e117-e122
    CrossrefPubMedGoogle Scholar
  • 22 Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 2018; 97 (07) 776-786
    CrossrefPubMedGoogle Scholar
  • 23 Gavrilov S, Karalkin A, Mishakina N, Efremova O, Grishenkova A. Relationships of pelvic vein diameter and reflux with clinical manifestations of pelvic venous disorder. Diagnostics (Basel) 2022; 12 (01) 145
    CrossrefPubMedGoogle Scholar
  • 24 Cheong YC, Smotra G, Williams AC. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev 2014; (03) CD008797
    PubMedGoogle Scholar
  • 25 Soysal ME, Soysal S, Vicdan K, Ozer S. A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. Hum Reprod 2001; 16 (05) 931-939
    CrossrefPubMedGoogle Scholar
  • 26 Rundqvist E, Sandholm LE, Larsson G. Treatment of pelvic varicosities causing lower abdominal pain with extraperitoneal resection of the left ovarian vein. Ann Chir Gynaecol 1984; 73 (06) 339-341
    PubMedGoogle Scholar
  • 27 Gargiulo T, Mais V, Brokaj L, Cossu E, Melis GB. Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Laparosc 2003; 10 (04) 501-504
    CrossrefPubMedGoogle Scholar
  • 28 Gilmore BF, Benrashid E, Geersen D, Shortell CK. Gonadal vein transposition is a safe and effective treatment of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord 2021; 9 (03) 712-719
    CrossrefPubMedGoogle Scholar
  • 29 Gloviczki P, Comerota AJ, Dalsing MC. et al; Society for Vascular Surgery, American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53 (5, Suppl): 2S-48S
    CrossrefPubMedGoogle Scholar
  • 30 de Carvalho SFC, Metzger PB, Fernandez MG, Ribeiro WB, Nogueira AKS. e Souza JPR. Pelvic venous reflux embolization in the treatment of symptomatic pelvic congestive syndrome: a systematic review with meta-analysis. J Vasc Surg Venous Lymphat Disord 2023; 11 (02) 412-421
    CrossrefPubMedGoogle Scholar
  • 31 Guirola JA, Sánchez-Ballestin M, Sierre S, Lahuerta C, Mayoral V, De Gregorio MA. A randomized trial of endovascular embolization treatment in pelvic congestion syndrome: fibered platinum coils versus vascular plugs with 1-year clinical outcomes. J Vasc Interv Radiol 2018; 29 (01) 45-53
    CrossrefPubMedGoogle Scholar
  • 32 Jambon E, Le Bras Y, Coussy A. et al. Embolization in pelvic venous disorders using ethylene vinyl alcohol copolymer (Onyx®) and Aetoxysclerol: a prospective evaluation of safety and long-term efficacy. Eur Radiol 2022; 32 (07) 4679-4686
    CrossrefPubMedGoogle Scholar
  • 33 Mahmoud O, Vikatmaa P, Aho P. et al. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord 2016; 4 (03) 355-370
    CrossrefPubMedGoogle Scholar
  • 34 Daniels JP, Champaneria R, Shah L, Gupta JK, Birch J, Moss JG. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol 2016; 27 (10) 1478-1486.e8
    CrossrefPubMedGoogle Scholar
  • 35 Brown CL, Rizer M, Alexander R, Sharpe III EE, Rochon PJ. Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Thieme Medical Publishers; 2018: 035-040
    Google Scholar
  • 36 Chen H, Wu Z, Wu Z. et al. Proximal coil occlusion preceding distal sclerotherapy in patients with pelvic congestion syndrome: a multi-center retrospective study. J Vasc Surg Venous Lymphat Disord 2022
    PubMedGoogle Scholar
  • 37 Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol 2006; 17 (2, Pt 1): 289-297
    CrossrefPubMedGoogle Scholar
  • 38 Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol 2000; 11 (07) 859-864
    CrossrefPubMedGoogle Scholar
  • 39 Meissner MH, Gibson K. Clinical outcome after treatment of pelvic congestion syndrome: sense and nonsense. Phlebology 2015; 30 (1, Suppl): 73-80
    CrossrefPubMedGoogle Scholar
  • 40 Nasser F, Cavalcante RN, Affonso BB, Messina ML, Carnevale FC, de Gregorio MA. Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. Int J Gynaecol Obstet 2014; 125 (01) 65-68
    CrossrefPubMedGoogle Scholar
  • 41 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 (04) 1006-1014
    CrossrefPubMedGoogle Scholar
  • 42 Chung M-H, Huh C-Y. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med 2003; 201 (03) 131-138
    CrossrefPubMedGoogle Scholar
  • 43 Meneses L, Fava M, Diaz P. et al. Embolization of incompetent pelvic veins for the treatment of recurrent varicose veins in lower limbs and pelvic congestion syndrome. Cardiovasc Intervent Radiol 2013; 36 (01) 128-132
    CrossrefPubMedGoogle Scholar
  • 44 Liu J, Han L, Han X. The effect of a subsequent pregnancy after ovarian vein embolization in patients with infertility caused by pelvic congestion syndrome. Acad Radiol 2019; 26 (10) 1373-1377
    CrossrefPubMedGoogle Scholar
  • 45 Bookwalter CA, VanBuren WM, Neisen MJ, Bjarnason H. Imaging appearance and nonsurgical management of pelvic venous congestion syndrome. Radiographics 2019; 39 (02) 596-608
    CrossrefPubMedGoogle Scholar
  • 46 Cura M, Cura A. What is the significance of ovarian vein reflux detected by computed tomography in patients with pelvic pain?. Clin Imaging 2009; 33 (04) 306-310
    CrossrefPubMedGoogle Scholar
  • 47 Labropoulos N, Jasinski PT, Adrahtas D, Gasparis AP, Meissner MH. A standardized ultrasound approach to pelvic congestion syndrome. Phlebology 2017; 32 (09) 608-619
    CrossrefPubMedGoogle Scholar
  • 48 Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Ovarian vein diameter cannot be used as an indicator of ovarian venous reflux. Eur J Vasc Endovasc Surg 2015; 49 (01) 90-94
    CrossrefPubMedGoogle Scholar
  • 49 Whiteley MS, Dos Santos SJ, Harrison CC, Holdstock JM, Lopez AJ. Transvaginal duplex ultrasonography appears to be the gold standard investigation for the haemodynamic evaluation of pelvic venous reflux in the ovarian and internal iliac veins in women. Phlebology 2015; 30 (10) 706-713
    CrossrefPubMedGoogle Scholar
  • 50 Black CM, Thorpe K, Venrbux A. et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol 2010; 21 (06) 796-803
    CrossrefPubMedGoogle Scholar