A scoping review of scores or grading systems for pelvic venous disorders.

Conception and design: KK, KM, MT, SG, ZL, AJ, SN, AG, AD Analysis and interpretation: KK, TP, AG Data collection: KK, TP, KM, AG Writing the article: KK, TP, KM, MT, AG Critical revision of the article: KK, TP, KM, MT, SG, ZL, AJ, SN, AG, AD Final approval of the article: KK, TP, KM, MT, SG, ZL, AJ, SN, AG, AD Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: KK

The following review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) guidelines. 11 The study protocol was made available online (identification No. 10.6084/m9.figshare.23735733). Included studies were full-text reports in the English language of original research studies (ie, randomized controlled trials, observational studies, cohort studies, case-control studies, validation studies), implementing a scoring or grading system specific for pelvic venous insufficiency, venous reflux, pelvic venous congestion, or pelvic origin varicose veins. The included studies implemented scores for any step of the diagnostic and management pathway for a cohort of patients with a confirmed or suspected PeVD. Case reports, editorials, commentaries, and opinion pieces were excluded. Studies that did not provide explicit information about a disease-specific scoring or grading system were also excluded. A systematic search was performed in MEDLINE and Embase bibliographic databases accessed via the OVID platform. A comprehensive search strategy was developed with a senior librarian (R.J.) to maximize the sensitivity of the search ( Appendix , online only). MeSH (medical subject heading) terms and free word searches were used. The references of the chosen studies and relevant reviews were searched to ensure the comprehensive inclusion of all relevant studies in this review. Two reviewers independently screened all the titles and abstracts generated by the search to remove irrelevant references. Next, the full text of potentially eligible studies were retrieved and independently assessed for eligibility by the same two reviewers. Any discrepancies were resolved through discussion, with involvement of a third reviewer if a consensus could not be reached. Data were extracted and recorded using a standardized data extraction form. The data extracted included authors, year of publication, sample size, country of origin, study design, and details of the scoring or grading system used, including its intended use and whether it is validated. The results were collated and summarized in a narrative form, discussing the nature and distribution of the studies, range of scoring or grading systems, and their components, validity, and clinical use. The results were accompanied by tables summarizing the main characteristics and findings of the included studies. Data were analyzed using SPSS, version 29 (IBM Corp). Continuous variables are summarized using the median and interquartile range (IQR). Discrete variables are summarized using numbers and percentages. Given the scoping nature of this review, the methodological quality or risk of bias of the included studies was not appraised, as recommended in the PRISMA-ScR guidelines.

A total of 3852 studies were identified from the search. After removal of duplicates, 2976 articles were screened. Of these, 2894 studies were excluded during the screening, because they did not fulfill the inclusion criteria. A full-text review was conducted on 82 articles; 20 of these studies were included. 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 Fig 1 shows the relevant PRISMA flow diagram. The key characteristics of the included studies are summarized in Table I . Only one study was published before 2000. Of the remaining 19 studies, 7 (35.0%) were published between 2000 and 2009, 4 (20.0%) between 2010 and 2019, and 8 (40.0%) after 2020. The median publication date was 2018 (IQR, 2003-2022). Of the 20 studies, 15 (75.0%) were published from European centers, 3 centers were in Asia, and 2 were in the United States. The median sample size was 90 patients (IQR, 58-220 patients). Most studies were retrospective cohort or prospective cohort studies, 10 (50.0%) and 6 (30.0%), respectively. Three were randomized trials and one was a validation study. Fig 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing study inclusion and exclusion in the study. Table I Characteristics of included studies Investigator Year of publication Country of publication Study design Modality used Szary et al 29 2023 Poland Retrospective cohort Clinical Sozutok et al 31 2022 Turkey Retrospective cohort Clinical Jambon et al 25 2022 France Prospective cohort Clinical Akhmetzianov 26 2022 Russia Validation study Clinical Gavrilov et al 23 2022 Russia Prospective cohort CT Neuenschwander et al 24 2022 Switzerland Retrospective cohort Clinical Gavrilov et al 22 2021 Russia Retrospective cohort DUS Szary et al 21 2021 Poland Retrospective cohort DUS, MRV, CTV Szaflarski et al 27 2019 USA Retrospective cohort CT Gavrilov et al 20 2019 Russia Prospective cohort Clinical Guirola et al 19 2018 Spain Randomized controlled trial Clinical Yang et al 18 2012 Korea Retrospective cohort MRV Asciutto et al 30 2009 Germany Retrospective cohort Clinical Asciutto et al 17 2008 Germany Prospective cohort MR and venography Hiromura et al 28 2004 Japan Retrospective cohort CT Scultetus et al 14 2003 USA Retrospective cohort DUS, clinical Chung et al 16 2003 Korea Randomized controlled trial Venography Soysal et al 15 2001 Turkey Randomized controlled trial Clinical Halligan et al 13 2000 UK Prospective cohort DUS Beard et al 12 1984 UK Prospective cohort Venography CT, Computed tomography; CTV, computed tomography venography; DUS, duplex ultrasound; MR, magnetic resonance; MRV, magnetic resonance venography. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing study inclusion and exclusion in the study. Characteristics of included studies CT, Computed tomography; CTV, computed tomography venography; DUS, duplex ultrasound; MR, magnetic resonance; MRV, magnetic resonance venography. A total of 21grading systems were identified (one study proposed two; Supplementary Table , online only). Of the 21 scores, 10 (47.6%) were clinical scores, and 10 (47.6%) were scores based on radiological findings; 1 score incorporated both clinical and radiological findings. 14 All clinical scores were patient reported; two were used for screening and eight assessed PeVD symptoms, before and after PeVD treatment. Three of the scores, from two studies, were validated. 12 , 26 Of the 11 scores that used radiological findings, the imaging modality used was duplex ultrasound (DUS; transvaginal and/or transabdominal) in 4 (36.4%), computed tomography (CT) in 4 (36.4%), magnetic resonance imaging or magnetic resonance venography (MRV) in 3 (27.2%), and venography in 3 scores (27.3%). The scores were further grouped into four main categories based on their use in the study: screening, diagnosis, measure of disease severity, or measure of response to treatment ( Fig 2 ). Of the 21 scores, 2 (9.5%) were used for screening, 3 (14.3%) were used to establish the diagnosis, 8 (38.1%) were used to assess some aspect of disease severity, and 8 (38.1%) were used to measure the response to treatment. Fig 2 Flow chart showing the steps of a diagnostic and management pathway and the number of unique scores or grading systems identified for each stage of the pathway. The identity of the score (ie whether it uses radiological or clinical findings) is also included. Flow chart showing the steps of a diagnostic and management pathway and the number of unique scores or grading systems identified for each stage of the pathway. The identity of the score (ie whether it uses radiological or clinical findings) is also included. Two studies used clinical scores for patients with suspected PeVD in a screening context. Neuenschwander et al 24 outlined a novel six-item screening questionnaire, which scored different symptoms of PeVD, including CPP for >3 months, visible vulvar or lower extremity varicosities, multiparity, and pain that worsened when upright, during sexual intercourse, or during menstruation. The maximum score was 10. Patients referred to their clinic who scored ≥3 were further assessed using DUS, and those with evidence of PeVD were included in the study. The average score of the women included was 7.1 ± 2.1. Guirola et al, 19 in their randomized control trial, used a five-item yes/no screening questionnaire, focusing on similar symptoms, including CPP for >6 months, dysmenorrhea, dyspareunia, low back pain, and visible varices. Similarly, patients with ≥3 positive answers were then assessed using DUS. Neither score was validated. Three studies described scores to establish PeVD diagnosis. 12 , 13 , 16 Two of them used venography and one used transvaginal DUS findings. Beard et al, 12 in their 1984 study, described and validated their pelvic venogram score; the other two scores were modifications of it. Beard et al 12 outlined a scoring system for assessing a pelvic venogram. It includes three aspects: 1. Maximum diameter of gonadal vein (1-4 mm, 5-8 mm, >8 mm) 2. Time to disappearance of contrast medium (0 seconds, 20 seconds, 40 seconds) 3. Congestion of gonadal plexus (normal, moderate, extensive) Maximum diameter of gonadal vein (1-4 mm, 5-8 mm, >8 mm) Time to disappearance of contrast medium (0 seconds, 20 seconds, 40 seconds) Congestion of gonadal plexus (normal, moderate, extensive) Each of these aspects is scored from 1 to 3 using the subdivisions outlined for a total score of 3 to 9. In their study, they investigated three groups of women: 45 women with a history of lower abdominal pain and normal pelvic findings on laparoscopy; 8 women with no symptoms and normal pelvic findings on laparoscopy (the control group); and 10 women with symptoms and some other, confirmed pelvic diagnosis (the pelvic pathology group). A score of ≥5 gave high diagnostic sensitivity and specificity for identifying women in the first group: 91% and 89%, respectively. Halligan et al 13 adapted the score for the assessment of pelvic vein morphology ascertained on transvaginal ultrasound, without Doppler, to quantify PeVD. Their score consists of three parts: 1. Vein number (0-2, 3-6, ≥7) 2. Vein diameter (5 mm) 3. Congestion assessment (normal, moderate, severe) Vein number (0-2, 3-6, ≥7) Vein diameter (5 mm) Congestion assessment (normal, moderate, severe) Each of the sections is scored from 1 to 3, using the subdivisions outlined, for a total score of 3 to 9. They reported no significant difference between the scores obtained by asymptomatic and symptomatic women (average score, 5.1 vs 4.5, respectively; P  = .182, unpaired t test). Halligan et al 13 concluded that transvaginal ultrasound is not sufficiently discriminatory to replace venography for diagnosis. Chung and Huh 16 modified the Beard et al 12 venogram score. Their scoring system consists of the following diagnostic criteria, assigning a value of 1 to 3 for each, depending on the degree of abnormality observed: 1. Gonadal vein diameter ≥6 mm 2. Contrast medium retention time >20 seconds 3. Existence of congestion in the pelvic venous plexus and/or opacification of the ipsilateral (or contralateral) internal iliac vein 4. Filling of vulvovaginal and thigh varicosities Gonadal vein diameter ≥6 mm Contrast medium retention time >20 seconds Existence of congestion in the pelvic venous plexus and/or opacification of the ipsilateral (or contralateral) internal iliac vein Filling of vulvovaginal and thigh varicosities Chung and Huh 16 used the total score obtained from these criteria to diagnose PeVD, with a venogram score of ≥5 being diagnostic. No validation of the score was reported. Of the 21 scores, 8 (38.1%) were used to assess the degree of severity of an aspect of PeVD: 4 (50.0%) assessed the degree of dilatation of any of the pelvic veins and 4 (50%) assessed the severity of reflux. All eight scores used findings from radiological investigations. Four scores assessing pelvic venous dilatation were identified. 14 , 17 , 21 , 27 The findings are summarized in Table II . Szary et al 21 proposed a morpho-hemodynamic classification of pelvic vein insufficiency using DUS, CT venography, and MRV data from 535 women with symptoms of PeVD. It consists of four primary grades (I-IV) of increasing severity, with two intermediate grades (I/II and II/III), defined by specific radiographic criteria, including gonadal vein diameter, degree of gonadal vein incompetence, and extent of involvement of parauterine veins and branches of internal iliac veins (through measurement of the vein diameter). Table II Summary of grading systems for dilatation of the pelvic veins Pelvic vein Szary et al 21 Scultetus et al 14 Szaflarski et al 27 Asciutto et al 17 Gonadal, mm GI, <6; GII, 8; GIV, >10 G2: 6-9 G3: >9 Mild, 8 Moderate, 5-10; severe, >10 Parauterine, mm GI: <5 GII: 8 NA NA Moderate, 5-10; severe, >10 Internal iliac, mm GI: <5 GII: 8 NA NA Moderate, 5-10; severe, >10 G, Grade; NA, not assessed. Summary of grading systems for dilatation of the pelvic veins G, Grade; NA, not assessed. The scoring system reported by Scultetus et al 14 categorizes patients with PeVD into three groups based on the severity of their symptoms and the size of their vulval varices: 1. Group 1 (1A and 1B): patients with mild symptoms and small vulvar varices (<3 mm diameter), mild pelvic discomfort, and mild pelvic reflux seen on DUS 2. Group 2 (2A and 2B): patients with predominant symptoms of pelvic congestion and medium-size vulvar varices (3-5 mm) and incompetent gonadal veins (6-9 mm diameter) 3. Group 3 (3A, 3B, and 3C): patients with severe symptoms impairing their lifestyle and large vulval varices (>5 mm), incompetent gonadal veins (>9 mm in diameter), and symptoms impairing their lifestyle Group 1 (1A and 1B): patients with mild symptoms and small vulvar varices (<3 mm diameter), mild pelvic discomfort, and mild pelvic reflux seen on DUS Group 2 (2A and 2B): patients with predominant symptoms of pelvic congestion and medium-size vulvar varices (3-5 mm) and incompetent gonadal veins (6-9 mm diameter) Group 3 (3A, 3B, and 3C): patients with severe symptoms impairing their lifestyle and large vulval varices (>5 mm), incompetent gonadal veins (>9 mm in diameter), and symptoms impairing their lifestyle Scultetus et al 14 reported that these severity groups impacted management decision making and treatment outcomes. Group 1 patients had excellent results with sclerotherapy alone, and patients in group 2 had better results with extraperitoneal resection of the gonadal vein compared with gonadal vein embolization alone. Group 3 patients required more complex management; 12 patients had severe symptoms with combined gonadal and hypogastric venous insufficiency. In these patients, hypogastric vein tributary embolization and gonadal vein resection, followed by sclerotherapy in the same session, were successful in nearly 90%. Szaflarski et al 27 provided a three-part grading system for gonadal vein dilatation (GVD). They conducted a quartile analysis on 1042 pelvic and abdominal CT scans of patients with GVD >5 mm. They concluded the following: 1. Mild GVD (25th percentile) was 8 mm Mild GVD (25th percentile) was 8 mm Finally, Asciutto et al 17 used MRV to grade the venographic appearance of congestion in the gonadal veins, internal iliac veins, and parauterine venous plexus: 1. Normal (small, straight, similar in caliber and easily visualized veins) 2. Moderate congestion (vein variable in caliber, tortuous, and difficult to see separately, diameter between 0.5 and 1.0 cm) 3. Severe congestion (wide veins, great variation in caliber, markedly tortuous, diameter >1.0 cm) Normal (small, straight, similar in caliber and easily visualized veins) Moderate congestion (vein variable in caliber, tortuous, and difficult to see separately, diameter between 0.5 and 1.0 cm) Severe congestion (wide veins, great variation in caliber, markedly tortuous, diameter >1.0 cm) They compared findings from MRV and venography. MRV had high sensitivity for the presence of congestion of gonadal veins (88%), hypogastric veins (100%), and pelvic plexus (91%). Four scores assessed the severity of reflux. Hiromura et al 28 propose a three-grade score for pelvic venous reflux using multidetector CT scans of 145 asymptomatic women. The grades correspond to the following hemodynamic patterns: 1. Grade I reflux: spontaneous reflux limited to the left gonadal vein (LGV) 2. Grade II reflux: spontaneous reflux limited to LGV and left adnexal veins 3. Grade III reflux: spontaneous reflux in the LGV, left adnexal veins, and, crossing the midline, to include any paravaginal, paraurethral, or right-sided pelvic veins Grade I reflux: spontaneous reflux limited to the left gonadal vein (LGV) Grade II reflux: spontaneous reflux limited to LGV and left adnexal veins Grade III reflux: spontaneous reflux in the LGV, left adnexal veins, and, crossing the midline, to include any paravaginal, paraurethral, or right-sided pelvic veins Yang et al 18 modified the scoring by Hiromura et al, 28 condensing it into a two-part grading of reflux, using time-resolved magnetic resonance angiography. 1. Grade 1 reflux: “reflux confined in the left gonadal vein and/or left parauterine veins” 2. Grade 2 reflux: grade I reflux plus “reflux in the right gonadal vein, the left internal iliac vein and the right internal iliac vein, and varicosities of the vulva and thighs” Grade 1 reflux: “reflux confined in the left gonadal vein and/or left parauterine veins” Grade 2 reflux: grade I reflux plus “reflux in the right gonadal vein, the left internal iliac vein and the right internal iliac vein, and varicosities of the vulva and thighs” Yang et al 18 concluded there was no significant difference between time-resolved magnetic resonance angiography and conventional venography to grade the degree of gonadal venous reflux. Furthermore, Gavrilov et al 23 proposed the “coefficient of pelvic venous congestion” as an objective assessment of venous congestion in both uterus and parametrium using single-photon emission CT with in vivo-labeled red blood cells. The precise technique is described in their report. In brief, the coefficient is a ratio of red blood cell activity counts, as measured on single-photon emission CT, in parametrial and common iliac veins. The proposed grading system is as follows: grade I, 0.5 to 1.0; grade II, 1.1 to 1.5; and grade III, ≥1.5. Symptomatic patients had a significantly higher coefficient than those who were asymptomatic (1.9 ± 0.4 vs 0.7 ± 0.2, respectively; P  = .008, Mann-Whitney U test). They also proposed a quantitative method for grading reflux on DUS. 22 They measured the duration of reflux: 1. Grade I: reflux lasting 1 to 2 seconds 2. Grade II: reflux lasting 2.1 to 5 seconds 3. Grade III: reflux lasting for >5 seconds Grade I: reflux lasting 1 to 2 seconds Grade II: reflux lasting 2.1 to 5 seconds Grade III: reflux lasting for >5 seconds A higher reflux grade correlated with greater severity of CPP measured using a visual analog scale (VAS). Eight patient-reported scores were used in seven studies as measures of severity of the signs and symptoms of PeVD before and after treatment. 15 , 20 , 25 , 26 , 29 , 30 , 31 In all seven studies, specific symptoms were scored individually, and the combined scores were used to calculate a total symptom burden score. One score was specifically designed to assess the QOL of patients with PeVD. Jambon et al, 25 Gavrilov et al, 20 Sozutok et al, 31 Asciutto et al, 30 and Szary et al 29 used the VAS with a score range of 0 to 10 to score each symptom. Akhmetzianov 26 and Soysal et al 15 used a scale from 1 to 3, with 3 indicating greater severity. The breakdown of symptoms assessed in each score is shown in Table III . Table III Symptoms assessed in scores measuring response to treatment Presentation assessed in score Jambon et al 25 Akhmetzianov 26 (PVCSS) Akhmetziano 26 (PVVQ) Gavrilov et al 20 Soysal et al 15 Sozutok et al 31 Asciuto et al 30 Szary et al 29 Pelvic pain Yes (VAS) – – Yes (VAS) Yes Yes a (VAS) Yes a (VAS) Yes (VAS) Dyspareunia Yes (VAS) Yes Yes – Yes Yes (VAS) – Yes (VAS) Postcoital pain Yes (VAS) Yes – – – – – – Menstrual pain Yes (VAS) Yes Yes – Yes Yes (VAS) – – Lower extremity pain Yes (VAS) – – Yes (VAS) – Yes a (VAS) Yes a (VAS) Yes b (VAS) Perineal pain – Yes Yes Yes (VAS) – – – – Difficulty walking Yes (VAS) – – – – – – – Aesthetic discomfort Yes (VAS) – – – – – – – Impact on daily working life Yes (VAS) – Yes – – – – – Psychological impact Yes (VAS) – Yes – – – – – Impact on physical activity levels – – Yes – – – – – Impact on mood – – Yes – – – – – Abdominal pain (heaviness and/or discomfort) – Yes Yes – – – – – Pain in sacrum/coccyx – Yes Yes – – – – – Varicose veins – Yes Yes – – – – – Pelvic pain on standing and during exercise – – – – – – – Yes (VAS) Urinary urgency – – – – – Yes (VAS) – – PVCSS, Pelvic venous clinical severity score; PVVQ, pelvic varicose vein questionnaire; VAS, visual analog scale (score, 0-10). a Assessed during sitting or standing position, separately. b Assessed during menorrhea/standing position, separately. Symptoms assessed in scores measuring response to treatment PVCSS, Pelvic venous clinical severity score; PVVQ, pelvic varicose vein questionnaire; VAS, visual analog scale (score, 0-10). Assessed during sitting or standing position, separately. Assessed during menorrhea/standing position, separately. The scores were sensitive to symptom improvement after management in most studies. More specifically, in the study by Gavrilov et al, 20 micronized purified flavonoid fraction (MPFF) was associated with a twofold reduction in the total score for all patients after 1 month. In the study by Jambon et al, 25 the median total score following embolization with ethylene vinyl alcohol copolymer (Onyx) was significantly lower than the preintervention scores (median, 3 of 100 [IQR, 0.00-7.25] vs 39 of 100 [IQR, 29.8-48.5]; P  < .001, Wilcoxon test). Soysal et al 15 showed that goserelin was more effective than medroxyprogesterone acetate at improving the total score (average change, 7.7 ± 1.8 vs 4.7 ± 1.4, respectively; P  < .001, Friedman two-way analysis of variance). Akhmetzianov 26 showed the score decrease discriminated against treatment and control groups. The average pelvic venous clinical severity score summary score decreased significantly by 3.4 ± 3.4 in the group treated with MPFF vs −0.2 ± 1.6 in the control group ( P  < .001, statistical test not stated). Szary et al 29 measured the total symptom score change after pelvic vein embolization (PVE) or PVE plus treatment of lower limb venous insufficiency. There was significant improvement in symptoms after treatment in both groups (average change: PVE, 11.6 ± 11.7; PVE plus lower limb venous insufficiency, 13.0 ± 14.0; P  < .05, Mann-Whitney U test). However, there was no significant between group difference. Asciutto et al 17 showed that patients who underwent gonadal vein embolization experienced significant improvement in symptoms (average score, 5.2 ± 3.5 before treatment vs 1.2 ± 0.9 after treatment; P  < .0001, Student’s t test). In contrast, patients with untreated incompetence experienced no symptomatic improvement (average score, 4.5 ± 1.6 before vs 5.1 ± 1.5; P  = NS, Student’s t test) after conservative treatment. Furthermore, Sozutok et al 31 used an eight-item VAS-graded questionnaire to quantify treatment efficacy. They demonstrated that endovascular gonadal vein embolization using only a coil was more successful in pain management than embolization using additional materials ( P  = .036, Student’s t test). 31 Akhmetzianov 26 proposed an additional PeVD-specific QOL score. In their study, in patients treated with MPFF, the average pelvic varicose vein questionnaire QOL index decreased significantly from 45.1 ± 14.7 at baseline to 36.6 ± 10.6 at end of treatment (average change, 8.2 ± 10.4). No significant change was observed in the control group (average change, −0.3 ± 4.0; P  < .001 for average change in QOL index between groups [statistical test not stated]). 26 The two scores by Akhmetzianov 26 were validated on a cohort of 397 women (304 with and 93 without PeVD) and demonstrated good construct validity and high sensitivity.

This comprehensive review of clinical scores and grading systems used in studies of PeVD identified 20 articles, which included 21 unique scores used in the diagnostic workup or management of PeVD. Of the 21 scores, 2 were used for disease screening, 3 were used to establish PeVD diagnosis, 8 were used to assess disease severity, and 8 were used as measures of response to treatment. Only three were validated. 12 , 26 The review identified heterogeneous reporting, both of disease severity assessment and of response to treatment. This was largely due to the absence of disease-specific evaluative tools and, historically, a lack of international consensus on disease classification. This review failed to identify a validated scoring or grading system intended for screening of patients presenting with symptoms suggestive of PeVD. Two nonvalidated scores were identified—these were used as screening tools in two prospective studies. Both scores were patient reported and assessed the severity of symptoms reported elsewhere as highly sensitive to PeVD such as CPP, dyspareunia, and dysmenorrhea. 6 , 7 Patients who scored high enough in both studies were further assessed for PeVD with DUS. In clinical practice, PeVD, although thought to account for ≤30% of cases of CPP, remain underdiagnosed. Patients often consult primary care and gynecology specialists before being referred to vascular specialists—this typically occurs only after ruling out other common causes of pelvic pain such as endometriosis, pelvic inflammatory disease, and fibroids. 24 A validated screening score for PeVD, incorporating features of these scores, could facilitate prompt referral, expediting the diagnosis, and potentially reducing healthcare costs by avoiding unnecessary invasive procedures. 32 Following screening, establishing the diagnosis is necessary. A recent systematic review described several studies investigating criteria for diagnosis of PeVD. 33 An important criterion is a gonadal vein diameter >6 mm on DUS, with evidence showing it has a positive predictive value of 83.3% for the diagnosis of PeVD caused by the gonadal vein. 34 However, Park et al 34 concluded that gonadal vein dilatation should ideally be combined with other parameters, including clinical symptoms and venographic findings, to establish the diagnosis. We attempted to identify whether scores combining multiple parameters have been described. One validated score used for PeVD diagnosis was identified—the venogram score, proposed by Beard et al 12 in 1984. This was validated on a cohort of 63 women. Since then, it has been widely cited and adapted for use with other imaging modalities. However, this score is solely based on an invasive investigation with associated risks of ionizing radiation, which currently is most often reserved for patients at the time of planned intervention. 35 , 36 , 37 Furthermore, it does not reflect our current understanding of the complexity of PeVD classification, as described by the American Vein & Lymphatic Society in their recently proposed symptoms, varices, pathophysiology (SVP) classification. 35 Finally, the validation was conducted on a cohort with high PeVD prevalence (45 of 63; 71.4%). This might have overly amplified the score's intrinsic measures of accuracy (ie the sensitivity and specificity), which, although mathematically independent of prevalence, have been shown to be affected by it through inherent biases introduced by a skewed cohort, such as patient spectrum bias. 38 , 39 Thus, this review has identified a pressing need for an updated score that can be used to diagnose PeVD and that reflects contemporary understanding, as presented in the SVP classification—this was also highlighted as the foremost research priority by an expert consensus panel. 10 Importantly, the SVP classification is a purely discriminative instrument, akin to the CEAP (clinical, etiologic, anatomic, pathophysiologic) instrument for lower extremity venous disease classification. 40 , 41 It can, therefore, not be used to measure disease severity or response to treatment—these are functions of evaluative instruments. 42 , 43 The review identified 16 evaluative scores/grading systems, 8 of which measured disease severity and 8 measuring the response to treatment. Various aspects of PeVDs were graded, including the degree of dilatation of pelvic veins, assessed on DUS, magnetic resonance imaging or MRV, degree of reflux in the pelvic veins, and clinical symptom severity. The scores assessing clinical symptom severity were used to measure the response to treatment and were sensitive to symptom improvement after treatment. It should also be noted that a number of tools have been reported in the literature as outcome measures in PeVD studies, including the venous clinical severity score, Von-Korf questionnaire, 44 and short-form McGill pain questionnaire. 45 Our objective was to identify disease-specific scores directly related to pelvic venous disease. These tools, although valuable for assessing venous disease severity and patient QOL in a broader sense, are not tailored specifically to PeVD, and, therefore, were not included. Furthermore, a validated disease-specific QOL instrument was identified—the pelvic varicose vein questionnaire. 26 Considering the principal effect of PeVD is on patients' QOL, standardizing reporting of QOL in clinical studies through the consistent use of a specific questionnaire will allow for better generalizability of results and, ultimately, better informed clinical decisions. Aspects of these scores could potentially be combined to provide a nuanced assessment of PeVD severity, incorporating clinical and radiological findings. These could further be used to assess and compare patients’ response to treatment. The SVP classification is central in the management of PeVD, guiding the approach from the initial diagnosis and disease classification through to clinical decision making. However, the SVP is a discriminative instrument and does not assess disease severity. Our review identified numerous scores or grading systems used for diagnosis, assessment of disease severity, and measuring the response to treatment. Most radiological scores assessed the gonadal vein, grading the severity of dilation and/or reflux, with little consideration of other sources of PeVD (eg, iliac venous compression). There was some correlation between the above and the severity of symptoms, which, in turn, affected clinical decision making and patient outcomes. 14 , 22 However, no scores were universally accepted or validated across all aspects of PeVD diagnosis, severity assessment, and treatment response. Furthermore, most included studies came from European centers. This likely does not reflect the overall output of pelvic venous research because we focused only on scoring systems; however, it highlights the need for promotion of international collaboration to specifically address these gaps. There is a need to develop a comprehensive scoring system that integrates clinical and radiological findings, reflecting the multifaceted nature of PeVD. This system should aim to standardize the diagnosis, facilitate effective management decisions, and objectively measure treatment outcomes. This would likely serve as an adjunct to the SVP instrument. The validation of such instruments must be context specific. 46 For tools aimed at community-based risk stratification and screening, validation should focus on ensuring accuracy in general practice settings to facilitate appropriate referrals to vascular surgery. Conversely, instruments evaluating post-treatment outcomes are best validated in specialized centers where pelvic venous interventions are performed. 46 , 47 A multiphase approach must be adopted, starting with a consensus among experts to establish a draft scoring system. This would be followed by pilot testing in appropriate clinical settings to assess feasibility and initial reliability. Subsequent larger scale, multicenter studies would then evaluate its external validity, diagnostic accuracy, and responsiveness to changes after treatment. The complexity of PeVD, characterized by patients presenting with multiple venous findings, necessitates a nuanced approach to validation. 35 , 48 This entails conducting studies that include diverse patient profiles to ensure the tool's applicability across the spectrum of disease severity and complexity. It is unlikely that one instrument will fit all. Also, such instruments will need adjustment to reflect the range of PeVD. In conjunction with the SVP, these instruments will enhance SVP utility in diagnosis, treatment, and monitoring and avoid unnecessary procedures for those without indicative symptoms. It would also support the standardization of care and help foster ongoing research, contributing to the evolution of best practices for managing pelvic disease. This study has several limitations. Primarily, the heterogeneous nature of the scores and grading systems identified did not permit an objective comparison of their relative discriminatory or evaluative abilities. Furthermore, most scores were used only in single studies, prohibiting any comments regarding their general practical utility. Finally, a scoping review, unlike a systematic review, although appropriate for our aim of identifying all scores and grading systems described in the literature, does not seek to assess the methodological quality or risk of bias in the included studies. 11 This work is, therefore, a purely descriptive account of the scores we found.

This scoping review identified a range of scoring and grading systems for PeVD. We note a lack of validated, up-to-date scoring systems, both clinical and radiological, for diagnosis, screening, and assessment of disease severity. This is an important first step in developing standardized, validated, and internationally applicable scoring systems for PeVD diagnosis and management.

None.