Pelvic Congestion Syndrome: CVR Doctor Trains Other Doctors

Peter Pappas, MD, Vascular Surgeon and Director of the Center for Vein Restoration (CVR) Venous and Lymphatic Fellowship Program, offers a continuing medical education (CME) presentation to doctors about pelvic congestion syndrome. Dr. Pappas is the lead physician in CVR’s Union, NJ, and Morristown, NJ, clinic locations.

What is Pelvic Congestion Syndrome?

Originally coined during the 1940s, pelvic congestion syndrome is “an old name for a common problem,” according to Dr. Pappas. Caused by dysfunctional veins in the pelvic area, this condition causes chronic, sometimes debilitating pelvic pain. Because the term “pelvic congestion syndrome” doesn’t adequately convey the many causes, signs, and symptoms of the condition, there is a movement underway among professionals in the field to rename it to pelvic venous disorders (PeVD). Dr. Pappas feels that PeVD better describes the multiple pelvic problems that primarily affect women, although the condition can also affect men.

Chronic Pelvic Pain Secondary to Pelvic Congestion Syndrome

Dr. Pappas explains that the problem with the term “pelvic congestion syndrome” is found in its classic definition, which requires that the patient experience pelvic pain for more than six months (not related to her monthly cycle). The problem with this definition is that many women visit the doctor with a vast array of different symptoms that may or may not be associated with chronic pelvic pain but are still secondary to a pelvic venous disorder.

How Common is Chronic Pelvic Pain?

Dr. Pappas demonstrates just how common chronic pelvic pain is by offering the following statistics:

• Two to 10 percent of all gynecological consultations are for some sort of pelvic pain
• Twenty percent of laparoscopies performed for pelvic pain is due to a pelvic venous disorder
• Of all the causes of pelvic venous disorder, up to 40 percent are due to pelvic venous insufficiency (PVI), which is a dysfunction in the veins in the pelvis

The Many Causes of Chronic Pelvic Pain

To emphasize the fact that there is a multitude of causes for chronic pelvic pain, Dr. Pappas presented an overview of other potential causes, which include:

Gynecologic: Including endometriosis, chronic pelvic inflammatory disease, fibroids, ovarian cysts, adhesions, and uterine prolapse.

Urologic: Including interstitial cystitis and recurrent urinary tract infections.

Gastroenterological: Including Irritable bowel syndrome (IBS), Inflammatory bowel disease (IBD), diverticular disease, chronic constipation, and hernia.

Neurologic: Including neuropathic pain and abdominal epilepsy/migraine.

Musculoskeletal: Including pelvic floor myalgia, piriformis syndrome, and psoas inflammation.

Hematological/Oncologic: Including cancer, fibromyalgia, sacroiliac joint pain, and fractured coccyx.

Signs and Symptoms of Pelvic Congestion Syndrome

Symptoms include:

• Pain that begins after a second or more pregnancies
• Pelvic bloating
• Painful vaginal intercourse (known as dyspareunia)
• Post-coital pain (pain after sexual activity) that can last minutes to hours after intercourse
• Intimacy avoidance due to fear of pain
• Waking during the night to urinate multiple times
• Pelvic pain or fullness with prolonged standing

Signs include:

• Varicose veins of the vulva (during pregnancy or that continue after pregnancy)
• Bulging varicose vein that runs across the pubic area
• Varicose veins high in the thigh area
• Varicose veins on the back of the upper thigh or down the outside of the thigh and leg where it meets the lower buttock
• Vaginal varicose veins

In the educational video, Dr. Pappas provides an illustration of the anatomy of the iliac and ovarian veins to demonstrate how reflux occurs. Ovarian reflux is when vein valves in the ovary do not close properly, resulting in backward blood flow, known as “reflux.” Iliac vein reflux is caused by a blockage in the vein that prevents blood from leaving the pelvis in a normal manner

Pelvic vein insufficiency is seen in about 40 percent of women with symptomatic pelvic congestion;

How is Pelvic Congestion Syndrome Diagnosed?

Gynecological perspective: Female patients who come to the Center for Vascular Medicine experiencing symptoms indicative of pelvic congestion first have a gynecological evaluation, including a transvaginal ultrasound to rule out Gynecologic causes of their pelvic pain. Endometriosis and ovarian cysts are the most common gynecologic causes for pelvic pain.

Gastroenterological perspective: Because they are also experiencing pelvic pain, patients often have had an evaluation by a gastroenterologist. These tests can include upper and lower endoscopy, abdominal and pelvic computerized tomography (CT) scan. Dr. Pappas warns that the abdominal and pelvic CT be done with intra-venous contrast, or risk missed interpretation by the radiologist.

Vein disease perspective: Dr. Pappas emphasizes that people experiencing chronic pelvic pain, with or without lower extremity pain and swelling see a vein specialist who can serve as the keystone who pulls together all the test results and interpret them with an eye toward correction of any venous dysfunction. After a thorough history and physical examination, the vein doctor will perform a trans abdominal venous duplex scan to search for evidence of an iliac vein stenosis (narrowing) and ovarian vein reflux. Based upon the history, physical and ultrasound data, the vein specialist will then inform the patient of their treatment options as well as the risks and benefits of each option.

For patients presenting with lower extremity pain, swelling and/or skin changes secondary to varicose veins, a venous duplex ultrasound that evaluates vein function and whether a blood clot is present should also be performed. Patients with persistent pain and swelling after treatment of their lower extremity varicosities should then proceed with a trans-abdominal ultrasound to determine if an iliac vein stenosis is present and possibly contributing to their persistent symptoms.

Dr. Pappas adds that, according to one of his recent peer reviewed publications, over 60 percent of women with pelvic congestion syndrome first present with lower extremity varicosities, pain, swelling and pelvic discomfort. A pelvic vein issue can present with lower extremity pain and swelling without pelvic symptoms. Persistent pain and swelling after addressing lower extremity varicosities are often a sign that a pelvic vein narrowing is present.

Long Term Results of Minimally Invasive Treatments for Pelvic Congestion Syndrome

Dr. Pappas discusses one of his clinical investigations published in 2018 in the Journal of Vascular Surgery: Venous and Lymphatic Disorders entitled “Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency.” The research studies two hundred and twenty-four women who came to Center for Vascular Medicine for pelvic pain. Their average age was 46 years, and they had experienced an average of over three pregnancies.

The study concluded that 80 percent of women demonstrated significant iliac vein stenosis (narrowing of veins located in the abdomen). And of those women who received ovarian vein embolization and iliac vein stent placement, their symptoms improved dramatically over women who received ovarian vein embolization alone. The exception is women in their twenties who, it was learned, should not be treated with embolization, and stenting as an initial therapy rather, they should have a thorough gynecological examination as their incidence of gynecologic disorders is higher in this age group.

Conclusions

• Pelvic congestion syndrome (pelvic venous disorders) accounts for 40 percent of all chronic pelvic pain.
• A good history and physical exam are keys to identifying patients with pelvic congestion syndrome.
• Transvaginal or transabdominal ultrasound with or without CT venography (a test that shows how blood flows through the veins) can often identify the vascular lesion (abnormal tissue).
• Treatment includes:
  • A thorough diagnostic venogram that evaluates the iliac, pelvic and ovarian veins
  • Stenting of stenotic venous lesions
  • Ovarian vein embolization on a selective basis
  • Varicography with foam sclerotherapy of veins deep in the pelvic
  • Lower extremity endovenous ablation (a procedure that uses heat to close varicose veins) with or without stab phlebectomies (a procedure to remove varicose veins, also called ambulatory phlebectomy) for lower extremity pain and swelling. Persistent pain and swelling after lower extremity treatment should mandate an evaluation of pelvic veins.

Why Partner With CVR?

Center for Vein Restoration, the clinical leaders in vein care, is looking for talented, dedicated physicians to join our team. CVR offers a physician-centric model with the freedom to maintain clinical control over medical decisions. If an opportunity to focus strictly on patient care while working with an organization dedicated to improving venous disease outcomes and awareness through philanthropy, innovation, education, and research sounds appealing, visit us at cvrstrongertogether.com.

Are You Experience Pelvic Pain? Call the Experts.

If you are experiencing chronic pelvic pain, go to the experts who conduct their own research and teach other doctors how to relieve pelvic pain. Call 240-965-3915 to discuss your concern with a patient care coordinator or visit centerforvein.com for more information.