For some women, when no obvious cause of pelvic pain is found, a gynaecologist may sometimes consider pelvic congestion syndrome.
This is a condition involving the veins of the pelvis. In affected women, some pelvic veins become enlarged, and blood may pool or flow abnormally within them. The resulting pressure can cause chronic pelvic pain.
Although it is generally considered within the field of gynaecology, PCS is a pelvic venous disorder, meaning that assessment and treatment may also involve vascular and interventional radiology specialists.
What does pelvic congestion syndrome feel like?
PCS typically causes dull, aching, heavy, or dragging pain in the lower abdomen or pelvis. The discomfort may be on one side or both sides.
There are several features that can provide clues. Pain may become worse after standing or sitting for prolonged periods, towards the end of the day, or after physical activity. Some women experience pain during or particularly after sexual intercourse. Symptoms may also worsen around menstruation.
Some women develop enlarged veins or varicose veins around the vulva, buttocks or upper thighs.
The condition is more frequently seen in women who have had pregnancies, but pregnancy is not a requirement for developing PCS.
Importantly, chronic pelvic pain has many causes. Endometriosis, fibroids, ovarian conditions, pelvic infection, bladder disorders and bowel conditions can all produce similar symptoms. Therefore, the presence of pelvic pain does not automatically mean that a woman has PCS.
How is it diagnosed?
Diagnosis begins with a detailed medical history and gynaecological examination. Your doctor will want to understand the location and duration of the pain, what makes it better or worse, menstrual symptoms, sexual symptoms, pregnancy history and any associated urinary or bowel complaints.
Pelvic ultrasound with Doppler is often an important first investigation. It can examine the pelvic organs while also assessing blood flow through the pelvic veins.
Depending on the circumstances, additional imaging such as MRI or CT may be recommended. These tests can provide more detailed information about the pelvic veins and identify possible venous compression or obstruction.
In selected cases, a specialist may recommend venography, an invasive imaging procedure that allows the pelvic veins to be examined in detail. This may also allow treatment to be carried out during the same procedure by an interventional radiologist.
One important point for patients is that enlarged pelvic veins on a scan do not, by themselves, prove that PCS is responsible for the pain. The imaging findings must fit the woman’s symptoms and clinical assessment.
How is it treated?
Treatment depends on the severity of symptoms and the underlying venous problem.
Some women may initially be treated conservatively with pain management and, in selected cases, hormonal therapy. However, persistent or severe symptoms may require more definitive treatment.
One of the main minimally invasive treatments is pelvic vein embolisation. An interventional radiologist passes a small catheter through a vein and uses coils or other materials to occlude abnormal veins. This reduces abnormal blood flow and allows blood to be redirected through healthier veins.
For women whose symptoms are caused by significant compression or obstruction of a major pelvic vein, venous stenting may sometimes be appropriate.
Major surgery is now required less frequently and is generally reserved for carefully selected patients.
When should you see your gynaecologist?
You should seek medical assessment if you have:
• Pelvic pain that persists for several months
• Pain that becomes worse with prolonged standing
• Significant pain during or after intercourse
• Unexplained pelvic pressure or heaviness
• New varicose veins around the vulva or upper thighs
• Pelvic pain that is interfering with work, sleep, relationships or daily activities
Message to women
Pelvic congestion syndrome is a recognised and potentially treatable cause of chronic pelvic pain. However, diagnosing it requires more than finding enlarged veins on an ultrasound. A careful assessment is essential to distinguish PCS from other causes of pelvic pain.
Women should not feel that they have to simply endure persistent pelvic discomfort. If your pain is affecting your quality of life, speak with your gynaecologist. In appropriate cases, collaboration between a gynaecologist, radiologist and interventional or vascular specialist can help establish the diagnosis and identify the most suitable treatment.
Dr Sherene Kalloo
MDW, MBBS, DGO, DM, FACOG
Specialist Obstetrician & Gynaecologist
