Pelvic congestion syndrome (female Pelvic venous congestion)

Pelvic congestion syndrome (PCS), or female pelvic venous congestion, is a condition or abnormal veins that causes chronic pelvic pain. The features include:

• Dull aches or throbbing pain in the pelvis, commonly towards the left side
• Commonly worse after standing for long periods (e.g., at the end of a day working on your feet)
• Commonly improved after lying down (e.g., first thing in the morning after sleeping)
• Not strongly related to periods (menstruation)

The cause of pelvic congestion syndrome (PCS), or female pelvic venous congestion, is reflux (backwards) flow through the gonadal (ovarian) vein, because the vein has become incompetent or leaky. This leads to engorgement and dilatation of the veins around the uterus and ovaries, causing the dull aches or throbbing pains. Women who have had children or who have varicose veins in the legs are more susceptible to developing pelvic congestion syndrome (female pelvic venous congestion). There may be concomitant "venous compressions" that can exacerbate pelvic venous congestion, including compression of the left renal vein, sometimes referred to as "Nutcracker syndrome," and compression of the left common iliac vein, sometimes referred to as "May-Thurner syndrome." Your Interventional Radiologist (IR) will discuss with you about these "venous compressions" if they are present, and develop an individualised treatment plan. It is not always best to treat (e.g., stent insertion) every site of compression upfront, as all treatments carry risks that must be considered.

Chronic pelvic pain is complex, and can have several different causes, some of which are more common and require more urgent attention than pelvic congestion syndrome, which is why pelvic congestion syndrome may be diagnosed after other conditions have first been excluded.

Ovarian vein (gonadal vein) embolisation is an evidence-based safe and effective minimally invasive treatment for pelvic congestion syndrome. Compared to other surgical treatments, including hysterectomy and ovarian vein ligation, embolisation provides the best long-term outcomes regarding improvement in pain and quality of life, shorter recovery times, and lower rates of complications, based on clinical trials and scientific studies.

Effectiveness

• >85% of women report improvement in chronic pelvic pain from pelvic venous congestion following embolisation
• In most women who experience improved symptoms after embolisation, the improvement is sustained long term (based on 2-3 year follow up)
• The rates of residual symptoms or recurrence are highly variable depending on a number of factors (including other sites of "venous compression" and future pregnancy).

1. A specialist interventional radiologist will first consult and examine you in the outpatient clinic to assess your symptoms and imaging, and consider the likelihood of your symptoms being due to pelvic congestion syndrome (PCS) and suitability for ovarian vein embolisation. If you are not suitable for embolisation, your Interventional Radiologist (IR) will discuss this with you and arrange referral to another specialist as appropriate.
2. Embolisation is performed under sedation and local anaesthetic, with passage of a small catheter tube into a vein in your neck or groin. The tube is then navigated into the ovarian (gonadal) vein and coils or liquid medication injected to seal the refluxing (reverse flow) vein.
3. You will be required to rest in bed either sitting up or lying down for up to 2 hours post-operatively, which is to minimise bruising.
4. Most women experience some pain post-procedure, typically a mild-moderate dull ache in the left pelvis, which is treated with pain medications
5. The procedure is performed as a day-case, and you will be able to go home the next day, returning to usual activities including work within 1 to 2 days
6. The chronic pelvic pain due to pelvic venous congestion is likely to gradually improve over the weeks to months following embolisation

The overall risk of complications is very low (<1%), but these can include:

• Groin or neck bruising
• Pelvic or lower back pain (dull ache)
• Coil migration

Interventional Radiologists (IRs) are specialty trained in the care of patients undergoing varicocele embolisation, including the pre-procedural assessment, operation and post-procedural care. Interventional Radiologists (IRs) are extensively experienced in embolisation procedures as they regularly perform embolisation in many areas of the body, including the lung, liver, spleen, kidney and pelvis.

Dr Matthew Lukies

Matthew has a particular interest in pelvic congestion syndrome (PCS) and ovarian vein embolisation treatment. During time training as a resident doctor, Matthew completed an advanced certification in Obstetrics & Gynaecology with the Royal Australian and New Zealand College of Obstetricians & Gynaecologists (RANZCOG), with whom he maintains associate membership. Matthew takes a patient-centred and shared decision-making approach to consulting about pelvic venous congestion, taking time to consider the broad range of potential causes of pelvic pain before recommending treatment.

Matthew has presented a both local and international scientific meetings about Pelvic Congestion Syndrome (PCS), including the Singapore College of Radiologists WIRES 2024 meeting, where he was awarded with the "Merit Poster" prize for his presentation.

It is important that you consider all causes and treatment options for Pelvic Congestion Syndrome (PCS), which includes medications and surgical options. After consultation with our interventional radiologist, your case may be discussed with or you may be referred to consult with a gynaecologist or pain specialist if you haven't previously seen one.

If you would like to consult with an Interventional Radiologist about uterine artery embolisation, please send a referral for consultation, including the following

• Ultrasound and/or MRI results
• Records of consultations with other doctors and specialists

Public eligible patients can undergo the treatment with no out-of-pocket expense in the public system.