Often during the course of my day as an interventional radiologist, I’ll take the time to explain arteries and veins at their most basic level.
Arteries are blood vessels, carrying blood away from the heart to various tissues. In arteries the blood is propelled by the pumping of the heart. Veins are a bit less intuitive to understand. For the most part, pressure and movement of blood in the veins is not subject to the pumping of the heart.
Blood travels through the veins primarily by local pressure changes around the vein (e.g., muscles contracting around veins of arms and legs during movement). This action works in combination with valves in the veins allowing flow only towards the heart and blocking flow in the opposite direction.
Disruption in the normal flow of blood through the veins and the subsequent build-up of static blood in veins can lead to varicose veins, varicoceles in men, and pelvic venous congestion syndrome in women. Pelvic pain is a very common complaint with estimates of up to a third of women experiencing it at some point in their lives. Pelvic congestion syndrome (PCS) is an underdiagnosed and undertreated cause of female pelvic pain.
The classic presentation of PCS is that of a multiparous woman complaining of dull aching pelvic pain persisting for more than six months. Exacerbating factors include prolonged standing, menstruation, and sexual activity. Given that the pain of
PCS is due to engorgement of pelvic veins, it should make sense that activities leading to increased blood flow to the pelvis would exacerbate the symptoms. Patients are usually parous since pregnancy increases pelvic vein capacity by 60 percent during which time the venous distension might leave pelvic veins incompetent. There may be associated varicose veins of the vulva, perineum, and lower extremities.
After history and physical exam (ovarian point tenderness and a history of postcoital pain is 94 percent sensitive and 77 percent specific for PCS), ultrasound should be the first line imaging study for PCS. Ultrasound may identify enlarged pelvic veins and reflux with Valsalva maneuver. CT and/or MRI may also be of benefit if coexisting pathology such as compressive tumors are suspected.
Historically, PCS was treated medically with limited effect using medroxyprogesterone acetate (Provera) or the GnRH agonist Goserelin. More recently, transcatheter therapy has increasingly become the first line of treatment. Typically the treatment involves embolization of the ovarian veins with coils and/or sclerosant medication. Occasionally, the internal iliac vein branches of the pelvis are also embolized. By embolizing the enlarged and incompetent veins responsible for pelvic pain, alternative collateral veins with competent valves take over and pain is relieved as the pelvic blood can return to the heart more easily from the pelvis following embolization.
The few studies published regarding response to treatment of PCS by transcatheter embolization have reported anywhere from 60 to 100 percent of patients reporting clinical benefit from the procedure.
The procedure is generally done with IV moderate sedation and patients generally go home the day of the procedure. Depending on the anatomy of the patient, the procedure can be done with access at either the neck or groin. The procedure will then usually take one to two hours.
There may be crampy pelvic pain following the procedure for a few days with most women recovering in one week or so. Reduction in pelvic pain typically occurs after two to three weeks.
By B. Bobby Chiong, MD, Chair, Department of Radiology