Pelvic congestion syndrome

Authors: M. Holý
Authors‘ workplace: Interní oddělení Nemocnice České Budějovice, a.  s.
Published in: Kardiol Rev Int Med 2014, 16(4): 321-329
Category: Internal Medicine


Pelvic congestion is a special form of chronic venous disease in women. This is defined as s syndrome which includes chronic pelvic pain, perineal discomfort, difficulties of micturition, and post‑coital pain in association with ovarian and/ or pelvic vein reflux. It may cause vulvar, perineal, gluteal and lower extremity varices. There is a close relation between symptomatic pelvic varices and renal nutcracker syndrome. Duplex ultrasound of abdominal, pelvic and lower extrem­ity veins and vulvoprineal region is the cardinal method of non‑invasive examination. MRI Venography is a highly sensitive technique for evaluating pelvic congestion. It may be used as a screening method or in cases of ambiguous sonographic findings and doubts. Pharmaceutical treatment options are limited, and therapy is based on venoactive drugs. Endovascular intervention –  ovarian/ iliac veins embolisation therapy and ilio‑ caval and renal venous stenting –  becomes the first line of treatment for women with severe symptoms, which are resistant to conservative approaches.

chronic pelvic pain –  varicose veins –  pelvic congestion –  renal congestion –  anatomy –  duplex ultrasound –  dia­gnostic criteria –  embolisation therapy –  renal venous stenting


1. Taylor HC jr. Vascular congestion and hyperaemia; their effect on structure and function in the female reproductive system. Am J Obstet Gynecol 1949; 57: 211– 230.

2. Eklof B, Perrin M, Delis KT et al. Updated terminology of chronic venous disorders: the VEIN‑ TERM transatlantic interdisciplinary consensus document. J Vasc Surg 2009; 49: 498– 501. doi: 10.1016/ j.jvs.2008.09.014.

3. Greiner M, Gilling‑ Smith GL. Leg varices originating from the pelvis: dia­gnosis and treatment. Vascular 2007; 15: 70– 78.

4. Marone EM, Psacharopulo D, Tshomba Y et al. A typical case of nutcracker phenomenon. J Vasc Surg 2011; 53: 219. doi: 10.1016/ j.jvs.2010.01.086.

5. Ramelet AA, Perrin M et al. Phlébology. Issy‑ les‑ Moulineaux: Elsevier Masson 2008: 61– 82, 167– 182, 429– 431.

6. Richardson GD. Managament of pelvic venous congestion and perineal varicosities. In: Gloviczki P et al (eds). Handbook of venous disorders. 3rd ed. London: Hodder Arnold 2009: 617– 626.

7. Phillips D, Deipolyi AR, Hesketh RL et al. Pelvic congestion syndrome: etiology of pain, dia­gnosis, and clinical management. J Vasc Interv Radiol 2014; 25: 725– 733. doi: 10.1016/ j.jvir.2014.01.030.

8. Belenky A, Bartal G, Atar E et al. Ovarian varices in healthy female kidney donors: incidence, morbidity, and clinical outcome. AJR Am J Roentgeol 2002; 179: 625– 627.

9. Labropoulos N, Tiongson J, Pryor L et al. Nonsaphenous superficial vein reflux. J Vasc Surg 2001; 34: 872– 877.

10. Perrin MR, Labropoulos N, Leon LR jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006; 43: 327– 334.

11. Venbrux AC, Chang AH, Kim HS et al. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol 2002; 13: 171– 178.

12. Monedero JL, Zubicoa ES, Grimberg M et al. Subdiaphragmatic venous insufficiency: embolization treatment using mixed technique (coils and foam). Phlebolymphology 2004; 45: 269– 275.

13. Asciutto G, Asciutto KC, Mumme A et al. Pelvic venous incompetence: reflux patterns and treat­ment results. Eur J Vasc Endovasc Surg 2009; 38: 381– 386. doi: 10.1016/ j.ejvs.2009.05.023.

14. Holý M. Syndrom pánevní kongesce. In: Roztočil K (ed). Angiologie. Praha: Triton 2014: 186– 192.

15. Creton D, Hennequin L, Kohler F et al. Embolisation of symptomatic pelvic veins in women presenting with non‑saphenous varicose veins of pelvic origin –  three‑year follow‑up. Eur J Vasc Endovasc Surg 2007; 34: 112– 117.

16. Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med 2003; 201: 131– 138.

17. Park SJ, Lim JW, Ko YT et al. Dia­gnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgeol 2004; 182: 683– 688.

18. D’Archambeau O, Maes M, De Schepper AM. The pelvic congestion syndrome: role of the "nutcracker phenomenon" and results of endovascular treatment. JBR‑ BTR 2004; 87: 1– 8.

19. Venbrux AC, Sharma GK, Jackson ET et al. Pelvic varices embolization. In: Ignacio E, Venbrux AC (eds). Women’s health in interventional radiology. Springer Science + Business Media, LLC 2012: 37– 59.

20. Kaufman JA, Waltman AC, Rivitz SM et al. Anatomical observations on the renal veins and inferior vena cava at magnetic resonance angiography. Cardiovasc Intervent Radiol 1995; 18: 153– 157.

21. LePage PA, Villavicencio JL, Gomez ER et al. The valvular anatomy of the iliac venous system and its implications. J Vasc Surg 1991; 14: 678– 683.

22. Jung SC, Lee W, Chung JW et al. Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings. Radiographics 2009; 29: 525– 536. doi: 10.1148/ rg.292085154.

23. Raffetto JD, Qiao X, Beauregard KG et al. Estrogen receptor‑ mediated enhancement of venous relaxation in female rat: Implications in sex‑related differences in varicose veins. J Vasc Surg 2010; 51: 972– 981. doi: 10.1016/ j.jvs.2009.11.074.

24. Raffetto JD, Khalil RA. Mechanism of varicose vein formation: valve dysfunction and wall dilation. Phlebology 2008; 23: 85– 98.

25. Asciutto G, Mumme A, Asciutto KC et al. Oestradiol levels in varicose vein blood of patients with and without pelvic vein incompetence (PVI): dia­gnostic implications. Eur J Vasc Endovasc Surg 2010; 40: 117– 121. doi: 10.1016/ j.ejvs.2010.01.023.

26. Oswald M, Heintz C, Wohllaib U. How to prove incompetence of the ovarian vein as a source of varicogenesis by testing the hormone content of the varicose veins of the leg. In: Phlebolymphology. Special issue for European Congress of IUP, Bremen 1999.

27. Reginald PW, Adams J, Franks S et al. Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion. Br J Obstet Gynaecol 1989; 96: 1148– 1152.

28. Rabe E. UIP Consensus Documents 2011. Bonn: Rabe Medical Publishing 2011: 99– 111, 131– 150.

29. Eliáš P, Žižka J. Dopplerovská ultrasonografie. 1. vyd. Hradec Králové: Nucleus HK 1998: 151– 184.

30. Scultetus AH, Villavicencio JL, Gillespie DL. The nutcracker syndrome: its role in the pelvic venous disorders. J Vasc Surg 2001; 34: 812– 819.

31. Reed NR, Kalra M, Bower TC et al. Left renal vein transposition for nutcracker syndrome. J Vasc Surg 2009; 49: 386– 394. doi: 10.1016/ j.jvs.2008.09.051.

32. He Y, Wu Z, Chen S et al. Nutcracker syndrome –  how well do we know it? Urology 2014; 83: 12– 17. doi: 10.1016/ j.urology.2013.08.033.

33. Hemalatha K, Narayani R, Moorthy M et al. Retro‑aortic left renal vein and hypertension. Bombay Hospital Journal 2008; 50: 6– 9.

34. Van Cleef JF. Treatment of vulvar and perineal varicose veins. Phlebolymphology 2011; 18: 38– 43.

35. Eberlová L, Tolar J, Mikuláš J et al. Variabilita hlubokých žil stehna. Cas Lek Cesk 2011; 150: 344– 346.

36. Gloviczki P, Comerota AJ, Dalsing MC et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and American Venous Forum. J Vasc Surg 2011; 53: 2S– 48S. doi: 10.1016/ j.jvs.2011.01.079.

37. Hiromura T, Nishioka T, Nishioka S et al. Reflux in the left ovarian vein: analysis of MDCT findings in asymptomatic women. AJR Am J Roentgeol 2004; 183: 1411– 1415.

38. Rozenblit AM, Ricci ZJ, Tuvia J et al. Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. AJR 2001; 176: 119– 122.

39. Kim HS, Malhorta AD, Rowe PC et al. Embolotherapy for pelvic congestion syndrome: long‑term results. J Vasc Interv Radiol 2006; 17: 289– 297.

40. Asciutto G, Mumme A, Marpe B et al. MR venography in the detection of pelvic venous congestion. Eur Vasc Endovasc Surg 2008; 36: 491– 496. doi: 10.1016/ j.ejvs.2008.06.024.

41. Moore CJ. Pelvic congestion syndrome update. Endovascular Today 2011; October: 24– 30.

42. Takebayashi S, Ueki T, Ikeda N et al. Dia­gnosis of the nutcracker syndrome with color doppler sonography: correlation with flow patterns on retrograde left renal venography. AJR Am J Roentgeol 1999; 172: 39– 43.

43. Kim SH, Cho SW, Kim HD et al. Nutcracker synd­rome: dia­gnosis with Doppler US. Radiology 1996; 198: 93– 97.

44. Fitoz S, Ekim M, Ozcakar ZB et al. Nutcracker syndrome in children. J Ultrasound Med 2007; 26: 573– 580.

45. Green IC, Cohen SL, Finkenzeller D et al. Interventional therapies for controlling pelvic pain: what is the evidence? Curr Pain Headache Rep 2010; 14: 22– 32. doi: 10.1007/ s11916‑ 009‑ 0089‑ 7.

46. Burak F, Gunduz T, Simsek M et al. Chronic pelvic pain associated with pelvic congestion syndrome and the benefit of Daflon 500 mg: a review. Phlebolymphology 2009; 16: 290– 294. doi: 10.1016/ j.ejvs.2008.06.024.

47. Ghosh A, Shafie‑ Pour H, Ayers K. Laparoscopic sclerotherapy in a case of pelvic congestion syndrome. BJOG 2006; 113: 610– 611.

48. Ahmed K, Sampath R, Khan MR. Current trends in the dia­gnosis and managament of renal nutcracker syndrome: a review. Eur J Vasc Endovasc Surg 2006; 31: 410– 416.

49. Marone EM, Psacharopulo D, Kahlberg A et al. Surgical treatment of posterior nutcracker syndrome. J Vasc Surg 2011; 54: 844– 847. doi: 10.1016/ j.jvs.2011.01.038.

50. Hartung O, Grisoli D, Boufi M et al. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: lessons learned from the first five cases. J Vasc Surg 2005; 42: 275– 280.

51. Baril DT, Polanco P, Makaroun MS et al. Endovascular management of recurrent stenosis fol­lowing left renal vein transposition for the treat­ment of Nutcracker syndrome. J Vasc Surg 2011; 53: 1100– 1103. doi: 10.1016/ j.jvs.2010.10.112.

52. Chen S, Zhang H, Shi H et al. Endovascular stenting for treatment of Nutcracker syndrome: report of 61 cases with long‑term follow up. J Urol 2011; 186: 570– 575. doi: 10.1016/ j.juro.2011.03.135.

53. Wang X, Zhang Y, Li C et al. Results of endovascular treatment for patients with nutcracker syndrome. J Vasc Surg 2012; 56: 142– 148. doi: 10.1016/ j.jvs.2012.01.007.

54. Monedero LJ, Zubicoa ES, Perrin M. Pelvic congestion syndrome: an update. Phlebolymphology 2013; 20: 145– 149.

55. Edwards RD, Robertson IR, MacLean AB et al. Case report: pelvic pain syndrome –  successful treatment of a case by ovarian vein embolization. Clin Radiol 1993; 47: 429– 431.

56. Nicolaides AN, Allegra C, Bergan J et al. Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence. International Angiology 2008; 27: 1– 59.

57. Monedero JL, Zubicoa ES. Left renal vein compression syndrome (LRV): current evaluation and endovascular treatment. Téchnicas endovasculares –  SITE 2013; 16: 56– 58. [online] Available from: http:/ / revista_XVI_numero1.php.

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