Pelvic pain is a common and distressing complaint among women of childbearing age. While there are quite a few established causes for pelvic pain in this age group, Pelvic Congestion Syndrome (PCS) is a specific diagnosis that is related to engorgement of veins within the pelvis. It is not uncommon for women to present for consultation to a vein surgical specialist for evaluation of throbbing varicose veins and ultimately the cause is found to be due to pelvic blood vessel problems.

Typical symptoms occur exclusively in premenopausal women. The pain is described as a dull ache in the pelvis and is a similar to the dull aching pain experienced by people with varicosities in the legs. The pain reported is predominantly on one side, but some patients report that the pain occasionally moves to the other side. The pain is made worse by prolonged standing or lifting. Although the pain exists throughout the menstrual cycle, occasionally it is worse just before the onset of menstruation. Dull pain after intercourse that lasts 2-4 hours is also typical.

For many years, the above complaints of female pelvic discomfort without an identifiable cause were unfortunately given the name of Pelvic Congestion Syndrome, signifying that this was a “syndrome” not well understood by physicians. In recent years, more thorough evaluations of these women correlated their physical findings of varicose veins of the vulva, perineum, buttock and high thighs with ultrasound exam findings of enlarged veins within the pelvis, usually located near the left ovary.

Previously, this type of pelvic pain was attributed to irritable bowel syndrome, endometriosis, adhesions from previous surgery or caesarian section. It was even reported that there was a psychological origin to these complaints! We now believe that this type of chronic pelvic pain is secondary to sluggish return of blood through the pelvic veins leading to congestion of pelvic organs and appearance of varicose veins in areas just external to the pelvis that are not the usual sites for varicose veins (see below).

The evaluation of all pelvic pain should start with a thorough gynecologic exam that may include an abdominal and intravaginal ultrasound. These two studies are safe, low risk exams that can tell much about the veins near the ovaries and uterus. Often, enlarging varicose veins are noticed by the presenting patient or her gynecologist that involve the vulva, buttock, upper inner thighs, and occasionally extending down the leg. An evaluation by a vein surgical specialist may be warranted to help narrow the diagnosis by evaluating the veins of the legs themselves.

After careful non-invasive studies that support the diagnosis of PCS, options are to perform an MRI study to further look at the pelvic veins or directly proceed to a venogram. The latter is an invasive exam with contrast dye but often treatment of PCS can be done simultaneously during the venogram.

Traditional treatment for PCS had been surgical closure of the culprit pelvic veins, usually on the left. While effective in reducing or eliminating pain, the procedure itself required a night or two in the hospital, general anesthesia and did leave a small flank scar. Today, the same results can be obtained by placing a catheter in the enlarged veins (after the venogram) and actually sending small metal coils along with medication down these malfunctioning veins in order to close them off. This procedure is done in a radiology suite with fluoroscopy. Studies have now shown this technique, in experienced hands, is as effective as surgery but without the need for an overnight hospital stay or scars. Discomfort is minimal and improvement in PCS pain should be appreciated within 4 weeks. Longer term, some patients have a recurrence of symptoms and require repeat investigation. Thankfully, this is an unusual event.

In summary, Pelvic Congestion Syndrome is now a well recognized medical condition in women which is related to malfunction of the pelvic veins. PCS pain affects the ability to live fully and can be the source of a number of disagreeable symptoms. PCS diagnosis and treatment is much better established and the results of minimally invasive treatment are favorable, safe and durable.