Chronic pelvic pain Pelvic congestion syndrome - genital varicose veins - diagnosis and treatment

What is chronic pelvic pain?

The definition of chronic pelvic syndrome is chronic pain in the pelvis, known as pelvic pain, that lasts for more than 6 months. In the genitals and perineum, or the pelvic floor between the two legs, there may be dilated veins, varicose veins (swollen veins in the lower limbs) and non-menstrual pain in the pelvis, as well as a feeling of constant heaviness, as shown in the picture below.

Figure 1

How common is it?

It is estimated that 25-30% of the female reproductive population will experience a pelvic pain problem. The percentage of women who have symptoms of pelvic congestion may increase after the second pregnancy.

How does pelvic congestion syndrome develop?

Pelvic congestion syndrome is caused by the incorrect resetting of the venous system. That is, it is the result of venous stasis. Due to the stagnation and stagnation of blood in the veins of the pelvic genitals, bladder and bowel, the blood cannot find a pathway of reflux and varicose veins in the genitals and lower limbs can be caused.

What are the causes of pelvic pain and clinical symptoms?

Causes
Chronic pelvic pain is a gynaecological, but also a vascular problem. For a correct diagnosis, we take into account pre-existing gynecological problems, such as endometriosis or ovarian cysts. The most common phenomenon is that, in 2-7 % during pregnancy, women develop varicose veins in the vulva, perineum and genitals, which usually disappear after delivery and reappear after the next birth.

The causes of pelvic congestion are usually of venous origin and can be multifaceted:

• Usually, it is due to compression syndromes, such as Nutcracker syndrome or May turner syndrome. The result of these compressive syndromes is venous insufficiency, i.e. the improper return of venous blood and the pooling of blood in the pelvis.
• Other causes may be an undiagnosed, older deep vein thrombosis or - in a very small proportion - arteriovenous malformation.

Clinical symptoms

The clinical symptoms, depending on the size of the condition, may be isolated or many may occur together. Usually, they are most severe 2 to 3 days before the period. Some of them are the following:

• Pelvic heaviness - chronic non-period pain
• Dyspareunia, i.e. pain during sexual intercourse
• Dysmenorrhea, i.e. painful menstruation with particular pain two days before the period
• Genital varicose veins, on the perineum, vulva, inside the buttocks
• Kidney pain and macroscopic hematuria
• Swelling of the lower limbs
• Pain and cramps in the legs after standing, pain especially on days of the period
• Recurrence of varicose veins mainly in the left lower limb
• Symptoms of irritable bowel syndrome

The diagnosis of pelvic syndrome

For the correct diagnosis of pelvic syndrome, a collaboration between a gynaecologist and a vascular surgeon is needed and usually the whole investigation takes time. Primarily, pre-existing gynaecological problems such as endometriosis, urological problems or irritable bowel syndrome and other similar conditions are excluded. The diagnosis is made by the following procedure:

• The doctor collects the patient's clinical history and records the symptoms
• On clinical examination, swelling of the lower limbs, especially the left, and the presence of varicose veins in the perineum and genitals may be observed
• An imaging test with ultrasound, magnetic resonance imaging or digital phlebography is performed

Ultrasound

The common and accurate diagnosis of chronic pelvic syndrome is made using the latest generation of ultrasound in two ways. By abdominal ultrasound and transvaginal ultrasound. During the examination, we identify the abnormal parts of venous insufficiency, hemodynamic compression (pressure point) and flow at specific points.

Figure 2

Figure 3

Magnetic venography

We perform MRI venography and use contrast fluid when we want to diagnose and visualize the pelvic veins and pressing symptoms, in order to decide on the planning of treatment.

Figure 4

Figure 5

Digital venography with venous puncture and use of contrast fluid

This method allows us to diagnose and treat the condition at the same time. We use it when we are sure that the patient is suffering from pelvic syndrome.

Treatment of pelvic congestion

The treatment of pelvic congestion syndrome, as well as the diagnostic investigation, involves a gynaecologist, a vascular surgeon and an interventional radiologist. Once other conditions that may cause chronic pelvic pain have been investigated and treated or ruled out and we have findings from imaging methods compatible with pelvic congestion syndrome, we plan the individualized treatment of each case, which may be:

• In the early form, with conservative treatments, use of phlebotonic drugs and elastic stockings of graduated compression.
• With analgesic or hormonal therapy, which can eliminate or help reduce symptoms.
• If the varicose veins are on the outside of the perineum and genitals or in the buttocks area, with the method of sclerosing foam without surgery (USGF sclerotherapy).
• The varicose veins are surgically removed by laparoscopy under general anaesthesia, as shown below in figure 6.

Figure 6

Modern treatment of pelvic congestion at the "Agios Loukas" Clinic

The modern treatment of venous disease is done with embolization and venous stenting. It is in the form of a day hospitalization in our clinic. It is done radio-invasively - intravenously by percutaneous puncture of the common femoral vein. It is a low-risk treatment and the patient is discharged from the Clinic after a few hours of observation.

Embolization is done under local anesthesia. By percutaneous puncture and with the help of catheters, embolization wires are inserted into the pathological sites and close these pathological veins, as shown in Figure 7.

Figure 7

By using a venous stent percutaneously, we insert the graft and thus treat the May Turner and Nutcracker pressure syndromes that cause pelvic congestion, as shown in Figures 8, 9 and 10.

Figure 8

Figure 9

Figure 10

Pelvic congestion syndrome is a chronic syndrome that can be treated. It is not always a gynaecological problem, and may require the intervention of a specialist vascular surgeon. Endovenous surgery offers a variety of treatment options if conservative means fail. Modern methods of venous stenting and embolization (coiling) are the most evidence-based. They are intravenous - radiation-invasive treatments with a short stay in the clinic. Clinical studies and systematic research show up to 80% successful results. With proper investigation, evaluation and treatment, the specialist can provide elimination of the pain and symptoms of pelvic congestion to greatly improve the patient's quality of life.

Text:
Dimitrios Papastavrou, MD, Doctor of Medical School Bratislava, Slovakia, Vascular and Intravenous Surgeon

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