REVIEW

CURRENT
OPINION Comprehensive review of pelvic congestion
syndrome: causes, symptoms, treatment options
Boleslaw Bendek, Nicole Afuape, Elizabeth Banks, and Nita A. Desai

Purpose of review
The purpose of this publication is to review the currently available and most up-to-date information
regarding the pathogenesis, diagnosis, and treatment of pelvic congestion syndrome.
Recent findings
The diagnosis of pelvic congestion syndrome is difficult to make; however, it should remain on the
differential for chronic pelvic pain. The most recent available research seems to favour endovascular
treatment with interventional radiology over surgical management, with high success rate and low
occurrence of complications.
Summary
High-level evidence on the diagnosis and management of pelvic congestion syndrome is lacking. Only a small
number of randomized controlled trials exist. More high-quality research is needed, particularly involving
practicing obstetrician and gynecologists as the majority of these patients, and the clinical outcomes of any
interventions implemented for pelvic congestion syndrome are ultimately managed by OB/GYN providers.
Keywords
pelvic congestion syndrome

INTRODUCTION which can lead to reflux or obstruction of the ovar-

Epidemiology
Pelvic congestion syndrome (PCS) is broadly defined
as chronic pelvic pain (CPP) caused by dilated and
dysfunctional pelvic veins. Pelvic varicose veins were
first described in the 1800s and the term PCS was first
used in the 1940s to describe CPP secondary to dilated
pelvic vessels. Fifteen to 40% of patients reporting
CPP are thought to have pain secondary to PCS.
However, studies have shown that dilated pelvic
vessels may also be present in asymptomatic women
& &
[1 ,2 ]. PCS is most commonly diagnosed in the third
and fourth decades of life and is generally associated
with multiparty; however, there are small studies that
&
depict PCS in nulliparous women [2 ]. PCS is rarely
seen in postmenopausal women; this is thought to be
secondary to lower estrogen levels. PCS is rarely
correctly diagnosed because of multiple presenting
symptoms, which can overlap with other causes of
& Creighton University, St. Joseph’s Hospital & Medical Center, Creighton
CPP and differing methods of diagnosis [1 ,3,4].
Pathogenesis
The cause of PCS is multifactorial, and is thought to
involve both mechanical and hormonal factors,
ian, gluteal or parauterine veins with resulting
venous dilatation.
Mechanical causes of pelvic vein dilation may
be secondary to intrinsic vein disorder (i.e. valve
incompetence, valve agenesis or malformations)
vascular compression or collateralization (i.e.
Nutcracker Syndrome, May–Thurner syndrome or
postvenous thromboembolism) or to extrinsic com-
pression caused by disorders, such as endometriosis
or tumor masses [3,4].
The venous drainage of the pelvis is complex as
it involves multiple venous plexuses and anatomy
may vary from person to person. In general, the
ovaries are drained via the ovarian veins, which
arise from the pampiniform plexus, which is con-
tinuous with the uterine plexus, and drains into
the inferior vena cava on the right and the renal
University School of Medicine, Phoenix, Arizona, USA
Correspondence to Boleslaw Bendek, 500W, Thomas Road, Suite 680,
Phoenix, AZ 85013, USA. Tel: +1 6024066017;
e-mail: boleslaw.bendek@dignityhealth.org
Curr Opin Obstet Gynecol 2020, 32:237–242
DOI:10.1097/GCO.0000000000000637

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Minimally invasive gynecologic procedures
KEY POINTS
 PCS is the result of dilated pelvic veins resulting in
chronic pelvic pain.
 PCS is difficult to diagnose given overlapping
symptoms with other causes of chronic pelvic
pain.
 Imaging alone remains nondiagnostic for PCS; a
patient should not be treated for an isolated clinical
finding of dilated pelvic veins, which is not associated
with pain.
 Diagnosis of PCS should be based on both patient
history and clinical findings.
 Clinical evidence regarding the efficacy of medication
therapy for management of PCS remains limited and
available therapies have not been shown to produce
long-term improvement.
 Endovascular treatment seems superior to surgery.
vein on the left. The uterus is drained via the uterine
vein. These veins then either drain into the ovarian
veins or into the uterine venous plexus, which
ultimately drains into the internal iliac veins. The
vesicovaginal plexus and the pudendal veins, which
drain the perineum, also ultimately drain into the
internal iliac veins. There are multiple connections
between the veins draining different regions of the
pelvis and the veins of the lower limb, one of the
most important being via the inferior gluteal vein.
This vein is large and valved but can cause signifi-
cant reflux into the veins of the lower limb and
pelvis if incompetent.
Valves are typically present at the distal end of
the ovarian veins to prevent reflux. In 15% of cases,
the left ovarian vein does not have valves, in 6% of
cases, the right ovarian vein does not have valves.
Unlike in other areas of the body, many of the pelvic
venous plexuses do not have valves and have weak
attachments between the adventitia and supporting
connective tissue. Therefore, the veins of the pelvis
are more susceptible to venous congestion. Addi-
tionally, the capacity of pelvic veins may increase
60-fold over the nonpregnant state, contributing to
both venous dilatation and valvular incompetence,
and thus incompetent valves and increased venous
diameter are found more frequently in multiparous
women [3–5].
There is no clear explanation for the pathophys-
iology of PCS-related pain. The current theory is that
ovarian venous engorgement results in the stretch-
ing of the intima, which then leads to the distortion
of the endothelium and smooth muscle cells within
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the vessels. Consequently, vasoactive substances,
including substance P (neuropeptide) and neuro-
kinins A and B, are released, which contribute to
inflammatory processes and pain. There may also be
potential mass effect from enlarged pelvic veins
leading to irritation of adjacent nerves [6].
Clinical features
PCS is described as dull, achy abdominal/pelvic pain
that is exacerbated after long periods of standing/
walking and improved with supine positioning.
Pain is worse at the end of the day. Pain may also
be exacerbated before or during menses. Pain during
intercourse with prolonged pain after intercourse is
& &
very typical of PCS [1 ,2 ,3–5]. The combination of
postcoital pain and ovarian tenderness on bimanual
examination is 94% sensitivity and 77% specificity
&
for PCS [1 ,5]. Other symptoms of PCS may also
include dysuria, urinary frequency and urgency,
perineal and lower extremity varicosities, vaginal
& &
discharge and neuropathy [1 ,2 ,3–5]. There are
no clinical features that are truly pathognomonic
to PCS; this combined with the fact that there is
significant symptom overlap with other pain causes,
makes PCS a challenging diagnosis.
Associated conditions
The cause of PCS may also be associated with ana-
tomical abnormalities, such as compression of the
left renal vein by the superior mesenteric artery
(Nutcracker syndrome). The literature also high-
lights development of pelvic varices secondary to
compression of the left common iliac vein by the
right common iliac artery (May–Thurner syn-
drome). In both conditions, dilation of the pelvic
vasculature may occur to alleviate upstream obstruc-
tion through collateral pathways [1 ,5].
&
Evaluation (examination, imaging)
A thorough clinical history and physical exam
should be conducted for all patients presenting
for evaluation of CPP. This should include a biman-
ual exam to assess for pain with manipulation of the
pelvic organs (cervical motion tenderness, point
tenderness over the ovaries or uterus) and evalua-
tion for other forms of venous insufficiency (vulvar,
rectal, and lower extremity varices) [7].
Ultrasound remains the first line imaging study
for evaluation of pelvic pain as it is helpful in ruling
out other diagnoses and for selecting patients for
further work-up. Transvaginal ultrasound offers
better visualization of the pelvic venous plexus,
and is unaffected by patient habitus or bowel gas.
Volume 32  Number 4  August 2020
 Comprehensive review of pelvic congestion syndrome Bendek et al.
Transabdominal ultrasound may be useful in the
setting of more central disease at the level of the
renal veins or common iliac veins. Upright posi-
tioning, color Doppler, and Valsalva may optimize
evaluation of valve competence using ultrasound
&
[8 ,9]. In their review of ultrasound for work-up of
pelvic pain in the nonpregnant patient, Patel et al.
highlighted the following additional findings:
(1) Tortuous parametrial/adnexal pelvic veins with
diameter more than 4 mm
(2) Tortuous and dilated arcuate veins in myome-
trium that communicate with the varicose veins
in the adnexa
(3) Slow blood flow (>3 cm/s) or reversal of blood
flow in the left ovarian vein, with/without
Valsalva maneuver
(4) Fifty percent of women have clusters of cysts
in ovaries. This polycystic appearance of ovaries
is not associated with hirsutism or amenorrhea
&
[10 ].
Dos Santos et al. [11] challenged the use of
ovarian vein diameter for diagnosis of reflux.
Computed tomography (CT) and MRI offer
cross-sectional imaging and detailed anatomical
survey of the pelvic vasculature and the surrounding
tissue. They allow for more thorough evaluation for
persistent external venous compression, such as in
the case of Nutcracker syndrome, compressive
&
tumors, cysts, or arterial aneurysms [8 ,9]. Direction
of flow may be difficult to determine by CT without
additional attention to bolus timing. Phase contrast
MRI technique may also optimize detection of
&
reflux [8 ]. MRI allows for avoidance of radiation
exposure and efficient identification of pelvic vari-
cosities with specificity reported up to 67–75% and
sensitivity up to 100% when compared with venog-
&
raphy [8 ]. CT and MRI are both superior to ultra-
sound in the identification of tortuous, dilated
pelvic and ovarian veins, broad ligament vascular
congestion, and ovarian varicocele [12].
Venography remains the gold standard for
diagnosis of PCS; however, it is usually preceded
by less invasive imaging work up. Transuterine and
selective retrograde ovarian and iliac catheter
venography are the two most common approaches
&
[12,13 ,14].
Isolated findings on imaging remain nondiag-
nostic for PCS; an asymptomatic patient should not
be treated for an incidental clinical finding of
dilated pelvic veins without associated pain.
Belenky et al. evaluated for ovarian vein incompe-
tence and retrograde flow in healthy female kidney
donors using preoperative abdominal aortography.
They reported a 9.9% prevalence of ovarian varices
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in the general population with only 59% demon-
strating clinical symptoms consistent with PCS [15].
Diagnostic laparoscopy alone may miss up to 80–
90% of PCS cases because of variceal decompression
secondary to supine positioning, Trendelenburg,
CO2 insufflation of the peritoneal cavity and adhe-
sions. Ultimately laparoscopy and imaging may assist
in ruling out other causes of chronic pelvic pain [7].
Diagnosis pelvic congestion syndrome
In 1984, Beard et al. [16] defined PCS as a condition
affecting multiparous, premenopausal women,
characterized by CPP of 6 months or longer with
visible congestion of pelvic veins on selective ovar-
&
ian venography. Jurga-Karwacka et al. [1 ] most
recently published a retrospective analysis, which
highlighted common associated characteristics in
their PCS patient population. Beard proposed an
objective system for classifying findings on venog-
raphy, which remains present in the currently
accepted criteria for venographic diagnosis of PCS:
(1) Venous reflux in the gonadal vein
(2) Incompetent pelvic veins defined as more than
5–10 mm in diameter
(3) Congestion of flow in the ovarian venous
plexus, of pelvic veins across the midline, of
vulvovaginal or thigh veins
(4) Opacification of thigh or vulvar varices, and
stagnation of contrast material in pelvic veins
&
[8 ,12].
If present, a dilated vein crossing the midline in
the uterine body is the most specific finding of PCS;
&
however, sensitivity of this finding is low [8 ,17]. As
mentioned previously, and isolated or incidental
finding of pelvic venous congestion on imaging in
a patient without associated clinical symptoms of
PCS is nondiagnostic.
In a 2010 Systematic Review, Tu et al. [18]
highlighted the lack of a validated diagnostic test
for diagnosis of PCS, further stating that existing
studies lack quality design and consistency with
measurement cutoffs. There remains a need for fur-
ther research in this area.
Differential diagnosis
The differential diagnosis of CPP is broad. One should
consider cause involving gynecologic, gastrointesti-
nal, urinary, vascular, nervous, and musculoskeletal
systems. Pain mechanisms may involve somatic, vis-
ceral, or neurologic pain pathways. When there is
concern for PCS, venous compression from an exter-
nal source must also be considered [12].
www.co-obgyn.com 239
Minimally invasive gynecologic procedures
Medical management
As the cause of PCS is believed to involve both
hormonal and mechanical mechanisms, inducing
a hypoestrogenic state via ovarian suppression and/
or vasoconstriction are primary goals of medication
intervention [19,20]. Clinical evidence regarding
the efficacy of medication therapy for management
of PCS remains limited, and available therapies have
not been shown to produce long-term improve-
ment. Past investigators have demonstrated tran-
sient pain improvement with nonsteroidal anti-
inflammatory drugs, medroxyprogesterone with
psychotherapy, GnRH agonists, and the etonoges-
trel implant [18,21–24]. There is limited data that
intravenous dihydroergotamine may be effective in
decreasing the size of uterine and parametrium
veins and alleviating pain symptoms; use is unfor-
tunately limited by transient efficacy and adverse
side effects [22]. Micronized purified flavonoid frac-
tion has also been reported by multiple investigators
to achieve significant reduction in pain within 2–4
weeks and improvement in venous outflow. The rate
of adverse effects, which included upper abdominal
pain, nausea, urticaria, and diarrhea was reported to
be less than 5% [25–28].
Surgical management
The surgical options currently available for the treat-
ment of PCS include alteration of the venous blood
flow and removal of the reproductive organs.
In a 1991 study of 36 patients with PCS treated
with hysterectomy and BSO, Beard et al. [29] con-
cluded that hysterectomy and BSO with hormone
replacement therapy is an effective treatment for
patients with CPP because of PCS; this study notably
did not have a control group. Later, Chung et al.
conducted a randomized control trial comparing
hysterectomy with unilateral or bilateral salpingo-
oophorectomy (BSO) with ovarian vein embolization
and concluded that embolotherapy was more effec-
tive in reducing patient symptoms. The mean visual
analogue pain scale (VAS) reduced from 7.8 to 3.2
(P < 0.05) in the embolization group, contrasting
with a reduction of 4.6 (P < 0.05) and 5.6 in the
hysterectomy with bilateral vs. unilateral salpingo-
oophorectomy groups respectively [30]. In the recent
International Union of Phlebology consensus, Anti-
&
gnani et al. [13 ] advised against hysterectomy as its
efficacy has not being proved convincingly. Hyster-
ectomy with BSO remains an option for women who
have failed other treatment modalities, but appropri-
ate counseling should be performed.
Surgical transperitoneal ligation of the ovarian
vein, has been associated with improvement in
pain in approximately 75% of patients [18]. The
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approach can be laparoscopy, robotic-assisted lapa-
roscopy or laparotomy. Surgical ligation can only
interrupt a limited number of refluxing veins, which
may result in recurrence. This approach allows the
surgeon to address other simultaneously existing
causes of chronic pelvic pain, that is, endometriosis.
Hibner et al. studied patients who were treated with
laparoscopic or robotic-assisted laparoscopic pelvic
vein ligation. Twelve out of 18 patients (67%)
reported an improvement in pain with change in
VAS at least 2 at the postoperative visit. Eight out of
the 12 patients had a long-term follow-up (mean
24 months); 3 patients reported resolution of pain,
7 patients reported continuing pain relief and 1
patient had recurrence of symptoms and underwent
hysterectomy with resolution of pain [31]. When
compared with endovascular treatment, surgery is
associated with longer hospital stay, longer recovery
time, and greater morbidity [20]. This approach
should be reserved for refractory cases, in patients
with debilitating symptoms who are appropriate
surgical candidates.
In 1993 Edwards et al. described the first bilateral
ovarian vein embolization for the treatment of PCS
[32]. It has become the mainstay of treatment for
patients with PCS caused by gonadal and pelvic vein
incompetence. Access can be obtained via the right
femoral, basilic, jugular, cephalic veins. Different
sclerotic agents can be used, including sclerosant
foam, glue, Amplatzer vascular plugs, and coils.
Multiple studies have evaluated this treatment
option, reporting mean success rate of 75% [33],
low recurrence rate of 5%, and relative safety [34–
36]. Despite the fact that this technique was first
described in 1993, the data regarding the gonadal
and pelvic vein catheterization is limited to a clini-
cal series and retrospective reviews. A larger series of
67 patients in 2007 demonstrated a pain reduction
as well as satisfaction with the treatment in 82%
[37]. Laborda et al. evaluated clinical outcomes and
patient satisfaction 5 years after coil embolization of
the gonadal and hypogastric veins in patients with
PCS and CPP. Clinical success was reported in 168
out of 202 patients (93.85%), with preprocedural
VAS of 7.34  0.7 decreasing to 0.78  1.2 at final
follow-up [38]. Some studies suggest that perform-
ing internal iliac vein embolization after the
gonadal vein embolization can improve outcomes,
particularly when reflux is present in more than one
vein [39].
Avgerinos et al. investigated the outcomes of left
renal vein stenting in the treatment of Nutcracker
syndrome; they reported that 13 out of 17 patients
(72.2%) reported symptom resolution or improve-
&
ment [40 ]. No complications were reported. Aver-
age follow-up time was 41.4 þ 26.6 months. Khan
Volume 32  Number 4  August 2020
 Comprehensive review of pelvic congestion syndrome Bendek et al.
& 5. Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent Radiol
et al. [41 ] described a case report of a patient with
PCS caused by May–Thurner syndrome with com-
plete resolution of symptoms at 12 month follow-up
&
following stenting of the common iliac vein [41 ].
CONCLUSION
Pelvic congestion syndrome remains a rarely diag-
nosed disorder in patients with chronic pelvic pain.
Detailed history, physical exam, and imaging can
assist with the diagnosis. Endovascular treatment
seems superior to open/laparoscopic management,
with high success rate and low occurrence of com-
plications. Unfortunately, only a small number of
randomized controlled trials have been performed
and high level evidence is thus lacking. Further,
most of the recent research articles that are available
for review are conducted by specialties other than
gynecology. Overall, PCS remains poorly defined
and has overlapping symptoms with other condi-
tions that have more clear diagnostic criteria and
proven treatments. Focused workup and interven-
tion for PCS should thus be reserved until after
investigation of other pain conditions is performed.
Acknowledgements
We would like to thank Dr Mario Castellanos and Dr
Michael Hibner for their assistance with this review.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
ı̈ of special interest
ı̈ı̈ of outstanding interest
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