Chronic pelvic pain in congestion pelvic syndrome: clinical impact and electromyography pelvic floor activity prior and after endovascular treatment

Chronic pelvic pain in congestion pelvic syndrome: clinical impact and electromyography pelvic floor activity prior and after endovascular treatment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Chronic pelvic pain in congestion pelvic syndrome: clinical impact and electromyography pelvic floor activity prior and after endovascular treatment Fabio Corvino, Francesco Giurazza, Milena Coppola, Antonio Tomasello, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3809569/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background To characterize clinical impact of endovascular treatment in Chronic Pelvic Pain (CPP) patients due to Pelvic Congestion Syndrome (PCS) and to assess the diagnostic value of surface electromyography (sEMG) study of pelvic floor musculature (PFM) in PCS patients pre- and post-endovascular treatment. Between January 2019 and July 2023, we studied consecutive patients who were referred for interventional radiology assessment and treatment to a tertiary trauma care Hospital, had evidence of non-obstructive PCS by Magnetic Resonance Imaging (MRI), had performed a sEMG of PFM and underwent endovascular treatment. The primary outcome was clinical, defined as change in symptoms severity after endovascular treatment. The secondary outcome was a difference in the sEMG values pre- and after endovascular therapy. Results We included 32 women (mean age 38 years). CPP was the leading symptom in 100% patients, followed by dysmenorrhea (75%) and post-coital pain (68.7%). Endovascular therapy included ovarian vein embolization in 28 patients (87.5%) and internal iliac vein embolization in only 2 patients (6.2%). After a median of 8 (range 6–10) months from endovascular treatment, 29 (90%) of patients reported improvement of the main symptoms, and 15 (46%) were symptom-free. The sEMG values didn’t show a statistical difference pre- and after PCS endovascular treatment. Conclusions Endovascular treatment appeared to be highly effective in CPP due to PCS and was associated with a low rate of complication. sEMG study could be useful in revealing alteration of PFM electrophysiology, but a difference pre and after embolization in PCS patient wasn’t demonstrated. Sclero-embolization Chronic pelvic pain Congestion pelvic syndrome Electromyography Pelvic floor activity Figures Figure 1 Figure 2 BACKGROUND Chronic pelvic pain (CPP) is a complex and disabling clinical condition among women of childbearing age; about one-quarter of women in reproductive age complain this clinical condition of greater one year in duration. The clinical symptoms are generally vague and inconsistent reflecting the multiple factors that have a role in its pathogenesis. The American College of Obstetricians and Gynaecologist define CPP as “pain of the pelvic region, sensed from the pelvic organs themselves that typically last more than 6 months”. Musculoskeletal, neurological and psychological conditions have been implicated in presentations of pelvic pain, but no diagnosis is made in over 60% of cases [ 1 ]. In 1948 Taylor firstly proposed a connection between the presence of pelvic varicosities and CPP [ 2 ]; this condition was classified as clinical entity, known as pelvic congestion syndrome (PCS), only after Beard et al. work of the 1980s, in which more than 90% of women with CPP presented in association pelvic varicosities [ 3 ]. However, more recent report described a prevalence of 39% of women with CPP and about 30% of these patients have a pelvic venous insufficiency related to PCS [ 4 – 5 ]. PCS is one of the main causes of CPP, accounting about 30% of these patients have a pelvic venous insufficiency. The pathophysiology of PCS pain includes the array of visceral, somatic and neurological pain generator [ 6 ]. In chronic lower extremities venous insufficiency, the pain state is related to abnormal vessel function [ 7 ]; Kaupilla 73 et al., about 4 decades ago, in a group of PCS patients affected by CPP demonstrated a higher rate of histological vascular anomalies (such as fibrosis, muscular hypertrophy and widened ovarian diameter) [ 8 ]. However, more recent views of pain states emphasize both peripheral and central contributors to nociception. Indeed, in some male affected by chronic pelvic pain, the presence of periprostatic pelvic varices have been described, suggesting a relationship between autonomic nervous system dysregulation of venous tone and some pelvic pain states [ 9 ]; similarly, the cerebral vasodilation seen in migraine headaches is thought to reflect neurological changes of the trigeminal system [ 10 ]. A correlation between CPP and dysfunction of the pelvic floor musculature (PFM) has been demonstrated; surface electromyography (sEMG) seems to be a useful tool to evaluate this kind of dysfunctions. CPP are closely associated with dysfunction of the PFM and the sEMG turned out to be a useful tool to assess this kind of patients. sEMG is the electric signal recorded by means of electrodes attached to the surface of the skin produced by the sum of the extracellular potentials from the active muscle fibers beneath the electrodes. A greater power of the PFM activity has been demonstrated in CPP patients than in healthy women, especially when compared with mature/parous subjects; this difference is related to an increased number of motor units recruited and the muscle fatigue caused by overactivation of the PFM [ 11 – 12 ]. The aim of our retrospective observational study is to analyze the clinical impact of endovascular treatment in CPP patients due to PCS and to assess the diagnostic value of sEMG study of PFM in PCS patients pre- and post-endovascular treatment. METHODS Patients. Between January 2019 and July 2023, 32 consecutive patients (mean age, 38 years; 29–60) with clinical diagnosis of CPP due to type 1 Greiner’s classification PCS underwent endovascular treatment in a major hospital of an Italian metropolitan city [ 13 ]. An Excel database was prospectively recorded and retrospectively analyzed. Data was collected from medical report, discharge letters and endovascular procedure report, including demographic information, relevant comorbidities and symptoms. Moreover, a clinical score, derived from a previously manuscript, was used to diagnose PCS and to evaluate clinical improvement [ 14 ]. The main demographic and clinical characteristics of patients are shown in Table 1 . Table 1 Main demographic and clinical characteristics of patients Patients 32 Age (years), mean ± SD 38.0 ± 5.4 BMI, mean ± SD 21.8 ± 2.8 Number of pregnancies, mean ± SD 1.6 ± 0.8 Comorbidities Uterine myomas, n (%) 5 (15.6) Endometriosis, n (%) 2 (6.25) Varicosis vein, n (%) 18 (56.25) Pelvic cysts, n (%) 4 (12.5) Deep vein thrombosis, n (%) 2 (6.25) Acquisite Arteriovenous Malformation, n (%) 1 (3.1) 26 (81.2%) of 32 patients had previous pregnancies (mean number of deliveries:2; 1–3) and only 2 had previous history of endometriosis treated with laparoscopic surgery in 1 case and with hormones in both cases. The most prevalent symptoms were CPP (100% of patients), dysmenorrhea (75%), post-coital pain (68.7%), dyspareunia (50%) and leg varicosities (48.8%) ( Table 2 ) . A pre-procedural Magnetic Resonance Imaging (MRI) imaging was performed in all patients to exclude the presence of a PCS related to a nutcracker syndrome, a May-Thurner one or other secondary causes. Table 2 Symptoms and PCS score at baseline of the study population Symptoms Baseline Chronic lower abdominal pain, n (%) 32 (100) Dysmenorrhea, n (%) 24 (75) Postcoital pain, n (%) 22 (68.75) Leg varicosities, n (%) 15 (48.8) Vulvar varicosities, n (%) 3 (9.3) Orthostatic pain, n (%) 10 (31.25) Dyspareunia, n (%) 16 (50) Back pain, n (%) 8 (25) Hemorrhoids, n (%) 4 (12.5) Depression, n (%) 2 (6.25) Dysuria, n (%) 2 (6.25) PCS score (mean ± sd) 7.2 ± 1.9 This study was approved by the local ethic committee and was conducted according to the Declaration of Helsinki principles. The human ethics review board at our institution approved the study design. Informed consent for data collection was obtained from all conscious patients. To characterize PFM activity a sEMG was carried out at baseline prior endovascular treatment and 6 months after it. The latency of the P40 response (n.v. 37.68 ± 2.60 msec), the P1-N1 amplitude (n.v.119 3.64 ± 1.01µV) and the latency of the R1 early response (n.v.<45 msec) were evaluated in the paraclitoral site ( Fig. 1 ). Contraindications to procedure include active pelvic infection, severe contrast medium allergy, coagulopathy and pregnancy. Endovascular technique. The procedure was undertaken in inpatient condition with mild analgosedation. Bilateral ovarian and iliac diagnostic subtraction phlebography was performed from femoral access to delineate the anatomy and identify the main vessels and collateral pathway, obtained with and without provocation such as Valsalva maneuver. Ovarian catheterization was achieved with a 5 Fr HET or another shaped tip catheter (COOK Medical, Bloomington, IN, USA) with a 0.038” lumen due to type of the coils utilized. In case where 0.018” micro-coils platform was utilized a 2.7 Fr Progreat Terumo (Terumo Medical, Tokyo, Japan) was used to delivery. A sandwich technique was preferred in all cases with pushable coils used after distal injection of 3% sodium tetradecyl sulphate (STS), prepared as a foam according to the Tessari method, with a maximum dose per procedure as 10 ml [ 15 ]. The complete occlusion with of the entire length of incompetent vein prevent possible future recanalization. Coils common sizes used range from 8 mm to 20 mm, generally oversized to prevent migration. Internal iliac veins were embolized with the same sandwich technique in cases where a venous reflux was confirmed at phlebography during Valsalva maneuver. Final phlebography control after embolization is undertaken to confirm vessel occlusion. In patients with symptomatic uterine myomas, a bilateral uterine artery embolization (UAE) was carried out in the same session. All procedures were performed by an interventional radiology radiologist with more than 5 years of experience. The primary cause of PCS was ovarian vein reflux highlighted in 29 patients (90.6%) ( Fig. 2 ) and internal iliac vein reflux in 1 patient (3.2%); in 3 patients (9.3%) phlebography demonstrated a combination of both. Ovarian vein embolization was performed in 28 patients (87.5%) and iliac vein embolization in 2 patients (6.25%). Findings from pelvic phlebography with fluoroscopy and therapeutic details are summarized in Table 3 . Table 3 Diagnostic and procedural data of patients Phlebographic findings Ovarian vein reflux, n (%) 29 (90.6) Internal vein reflux, n (%) 11 (34.3) Vulvar vein reflux 1 (3.1) Main pathology Ovarian vein insufficiency, n (%) 28 (87.5) Internal iliac vein insufficiency, n (%) 1 (3.2) Both 3 (9.3) Treatment Ovarian vein embolization, n (%) 28 (87.5) Left, n (%) 24 (75) Right, n (%) 12 (37.5) Bilateral, n (%) 8 (25) Internal iliac vein embolization, n (%) 2 (6.25) Left, n (%) 1 (3.25) Right, n (%) 1 (3.25) sEMG signal Recording Technique. sEMG signal was recorded in each patient from the left and right sides of the pelvic floor in a dorsal lithotomy position with adhesive electrodes. The study of the sacral evoked potentials was carried out with a manual bipolar stimulator with cathode in the paraclitoral site and recording using surface electrodes in the parietal region CZ (-2 cm) – FPZ according to the international 10–20 system, with square wave stimulation of the duration of 0.5 msec, intensity 3–4 times the sensory threshold, frequency 1.5 Hz, 151 impedance < 5 kOhm, bandwidth 1 Hz-3 kHz, 200 stimuli. The latency of the P40 response (n.v. 37.68 ± 2.60 msec) and the P1-N1 amplitude (n.v. 3.64 ± 1.01µV) were evaluated. The anal pudendal reflex was evaluated with a manual bipolar stimulator with the cathode positioned in the paraclitoral site and recording by means of coaxial needle electrodes from the external anal sphincter muscle. The latency of the R1 early response was evaluated (n.v.<45 msec). Study endpoints and definition. Primary clinical success was defined as the change in symptoms severity following 6-months endovascular therapy. Symptoms relief was divided in three categories relating to its improvement: 1. Complete freedom from PCS symptoms; 2. Improvement with residual symptoms; 3. No improvement or changes of symptoms. Secondary clinical outcome was defined as a difference in the sEMG study between the single parameters studied before and after endovascular treatment. Technical success was defined as the successful endovascular procedure with no further evidence at imaging of reflux. Safety outcome was defined as the prevalence of peri and post-operative complications, categorized according to CIRSE guidelines [ 16 ]. Follow-up and clinical outcome. Median follow-up was 8 months (range 6–10 months). Clinical improvement was demonstrated in 29 patients (90%) with 15 patients (46%) having complete resolution of symptoms. In 3 patients (9.3%), endovascular treatment did not improve symptoms. One patient had history of endometriosis with previous multiple surgical laparoscopic interventions. The second one had previous history of sacral trauma with associated a significant increase of R1 latency of the anal pudendal reflex, directly related with a neuronal impairment. The last one had previous history of urolithiasis with different previous urological procedure. In one case with no resolution of vulvar varices after ovarian sclero-embolization, the patient underwent to direct percutaneous STS foam sclerotherapy with complete resolution. The latency values of P40 response pre-treatment are slight reduced compared to normal value; compared to pre-treatment value, the latency of P40 response was slight increased after treatment but not with a statistical significance. An increase of P1-N1 signal amplitude in PCS was demonstrated; moreover, a reduction of signal amplitude after PCS treatment was demonstrated but with no statistical significance. There was no statistically difference before and after endovascular treatment in study of R1 latency of the anal pudendal reflex. The sEMG values pre and after embolization are summarized in Table 4 . Complications due to endovascular procedure occurred in 4 patients (12.5%): in 2 patient (6.25%) partial coil migration into inferior vena cava in one patient and in left renal vein in another one was promptly retrieved by snaring techniques during endovascular procedure (Grade 1 CIRSE classification); 2 patient (6.25%) suffered mild symptoms of pelvic thrombophlebitis successfully treated with low molecular weight heparin (LMWH) (Grade 3 CIRSE Classification). Table 4 The sEMG values evaluated pre- and after- PCS sclero-embolization. sEMG signals Pre-embolization After embolization p value Latency p40 response 32.85 ± 1.40 msec 34.05 ± 2.30 msec ≥ 0.05 P1-N1 amplitude 4.26 ± 0.96 µV 3.96 ± 0.85 µV ≥ 0.05 Anal pudendal reflex 40 ± 2 msec 39 ± 3 msec ≥ 0.05 DISCUSSION CPP has a worldwide population prevalence of 15% in female population between 18 and 50 years and in 61% of cases the etiology is unexplained. Labeling pelvic pain patients with single pathologic diagnoses such as PCS may hinder treatment efforts; however, a prevalence estimated around 30% of PCS in CPP patients has been demonstrated [ 17 ]. The pathogenesis of PCS is still unclear, but it has been demonstrated its multifactorial nature. Pregnancy hyper flow venous condition, in terms of gonadal and pelvic plexus dilated, due to estrogen level vasodilator effects could one of the pathogenetic factor involved. A main role, in addition, is related to a valve incompetence development and/or stenosis/obstruction onset of the draining veins [ 18 ]. The type 1 Greiner’s classification PCS treated in our study, that is a non-obstructive left ovarian vein insufficiency and reflux, is the most common pathophysiological cause with a prevalence of more than 50% of cases. In 2021 Meissner et al. proposed the Symptoms-Varices-Pathophysiology (SVP) classification of pelvic venous disorders: however, its effective role in determining treatment has still to be demonstrated [ 19 ]. A novel PCS management strategy proposed an association between a simple screening tool - the PCS score - that gynecologists and primary care physicians could use, and an accurate noninvasive imaging; this synergy, also used in our study, seems to improve the PCS diagnosis and successful rate treatment [ 14 ]. A non-invasive imaging study is mandatory in PCS management strategy, primarily to confirm the clinical suspect of PCS and secondly to exclude other CPP causes [ 17 ]. Ultrasound (US), both transabdominal and transvaginal, with colour Doppler imaging and Doppler spectral analysis should be used in PCS diagnosis. A dilated and tortuous pelvic vein (diameter > 6 mm), a slow blood flow (< 3cm/s) or reversal caudal flow, a dilated arcuate veins and polycystic changes in the ovaries are the ultrasound diagnostic criteria for PCS diagnosis [ 20 ]. MRI represent the first line of investigation, providing better imaging of the many causes of CPP and, due to the patient young age, should be preferred to Computed Tomography (CT) given the absence of ionizing radiation. MRI has shown a sensitivity and specificity of 88% and 67%, respectively, in demonstration of ovarian veins congestion. However, CT and MRI studies are both performed in supine position, thus being able to underestimate venous dilation compared to US and phlebography where provocative maneuvers could be employed. In our cases, a prior MRI study with demonstration of pelvic venous congestion for ovarian veins and MR angiography sequence with detection of vein dilatation and reflux was mandatory [ 21 ]. Catheter phlebography still remains the gold standard for PCS diagnosis, but its diagnostic role is reserved only in cases when noninvasive studies are inconclusive [ 22 ]. PCS treatments proposed and used in time are multiple and include conservative, psychological, medical, surgical and endovascular options, both in isolation and in combination. An RCT comparing combined hormone suppression and psychotherapy experienced sustained CPP relief with a > 50% reduction 262 in pain score [ 23 ]. A medical therapy, alone or in combination with other treatment, didn’t demonstrated a superior efficacy than another but only an increase of adverse symptoms if used in a long-term setting [ 24 ]. Surgical treatments include different alternatives including a mini-invasive laparoscopic approach for ovarian veins ligation to a more invasive one as hysterectomy and/or oophorectomy. Only one study published by Gargiulo et al. demonstrated an extraordinary 100% symptoms relief in 23 women treated with a laparoscopic ovarian vein ligation treatment [ 25 ]. Finally, hysterectomy, proposed when all other treatments have failed, showed a 22–33% of failure rate in clinical symptoms resolution [ 26 ]. Endovascular management of PCS is recommended with a level 2B evidence by the Society of Vascular Surgery: “We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or trans-catheter sclerotherapy, used alone or together” [ 27 ]. Our study confirms the actual literature about the difference rate between technical success (almost always described above 95%) and clinical success (usually between 58% and 100%), regardless of the embolic agent. To date, there have not been any randomized study comparing clinical success using different embolic agents for PCS endovascular treatment. The choice of embolic agent is generally operator dependent with no different outcome described with use of a specific agent [ 17 ]. Moreover, such a high technical success with a low complication rate allows us to conclude that endovascular techniques are safe and effective in PCS syndrome tretment. Clinical outcome is in line with previous literature and it could be considered as overall positive. 90% of patients showed a clinical improvement with 46% of patients having complete resolution of symptoms; in only 3 patients (9.3%), endovascular treatment did not improve symptoms. A recent meta-analysis demonstrated a short-term outcome similar to our study, showing a clinical improvement in 88% of patients and a 6–32% of patients that not experienced any symptom relief [ 28 ]. Another comprehensive review in 2018 stated that of the 1308 patients included in the study about 75% reported an early symptoms relief after embolization [ 29 ]. CPP and other clinical condition of the pelvic floor (i.e., fecal incontinence, organ prolapse, etc…) are closely associated with disfunction of the pelvic floor musculature PFM, so that sEMG could be a useful tool to assess patients’ clinical conditions [ 11 ]. In our study, the baseline value of the latency of p40 response and P1-N1 signal amplitude confirm that a slight muscular hypertonia is associated with CPP due to PCS; however, these values after PCS endovascular treatment point out that this correlation, is not directly connected with venous insufficiency, but there are subtle other pathologies related that should be studied further. The R1 latency of the anal reflex comparison show no difference between pre and after treatment; this type of evaluation is directly related with neuronal impairment that is highlighted in only one patient. The results obtained prove that sEMG can reveal alterations in the PFM electrophysiology associated with CPP related to PCS and provide clinicians with objective information that can help them to better evaluate CPP patients’ condition, thus allowing more efficient management of this complex syndrome. Future studies of PCS-related pelvic pain should also evaluate central mediators of vascular tone, perhaps by employing biofeedback or stress reduction. Anxiety and depression in this group of women has long been recognized with much debate as to whether this cause or effect. Farquhar et al. postulated that in a population of PCS patients, only women on combined hormone suppression and psychotherapy experienced sustained CPP relief, pointing out that overlapping neurological and hormonal factors can influence pain symptom expression [ 23 ]. Even though the sample size was homogenous, our study has several limitations. First, the sample size studied was small. Second, the evaluation only of patients with a type 1 Greiner’s classification PCS, makes the population more homogeneous, ruling out patients with type 2 and 3 of PCS syndrome, that asses more than 40% of patients with PCS. Third, all patients were recruited by only one interventional radiology center that could bring a selection bias. Last, the absence of a comparison healthy population studied with sEMG. However, given the absence in literature of a randomized controlled trials on management and treatment strategy of PCS with also sEMG study of PFM, our data may provide a reference for a future trial. CONCLUSION Currently, the management of women with chronic pelvic pain is suboptimal, with only 40% of affected women being referred to a dedicated specialist. Endovascular therapy should be chosen over a less effective medical (psychotropic, hormonal or venoactive drugs) and a more invasive surgical approach, highlighting that PCS is a multifactorial disease where vein disease is only one side of a more complex pathology [ 4 ]. The slight differences found between PFM activity in PCS patients prior and after endovascular treatment prove that sEMG could be a useful tool for a selected patients and more studies are necessary for identify its role in CPP clinical diagnosis and management. Declarations This study was performed in line with the principles of the Declaration of Helsinki; All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments; Informed consent was obtained from all individual participants included in the study; The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request; The authors declare that no funds, grants, or other support were received during the preparation of this manuscript; The authors have no relevant financial or non-financial interests to disclose; All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by G. F., C. M., N. R.. The first draft of the manuscript was written by C. F. and C. A. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript; The authors declare that they have no conflict of interest. References Liddle AD, Davies AH (2007) Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology 22(3):100–104. 10.1258/026835507780807248 Taylor HC Jr (1949) Vascular congestion and hyperaemia: their effect on structure and function in the female reproductivesystem. Am J ObstetGynaecol 57:211–278 Beard RW, Highman JH, Pearce S, Reginald PW (1984) Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet ii:946–949 Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC (2006) Embolotherapy for pelvic congestion syndrome: long-term results. J VascIntervRadiol 17:289–297. 10.1097/01.RVI.0000194870.11980.F8 Brown CL, Rizer M, Alexander R, Sharpe EE 3rd, Rochon PJ (2018) Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin InterventRadiol 35(1):35–40. 10.1055/s-0038-1636519 Howard FM (2003) Chronic pelvic pain. Obstet Gynecol 101(3):594–611. 10.1016/s0029-7844(02)02723-0 Nicolaides AN (2003 Jul-Aug) From symptoms to leg edema: efficacy of Daflon 500 mg. Angiology 54(Suppl 1):S33–44. 10.1177/0003319703054001S05 Kauppila A (1970) Uterine phlebography with venous compression. A clinical and roentgenological study. Acta ObstetGynecolScand Suppl 3(Suppl 3):1–66. 10.3109/00016347009155062 Terasaki T, Watanabe H, Saitoh M, Uchida M, Okamura S, Shimizu K (1995) Magnetic resonance angiography in prostatodynia. Eur Urol 27(4):280–285. 10.1159/000475181 Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW (1989) A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J ObstetGynaecol 96(10):1153–1162. 10.1111/j.1471-0528.1989.tb03190.x Albaladejo-Belmonte M, Tarazona-Motes M, Nohales-Alfonso FJ, De-Arriba M, Alberola-Rubio J, Garcia-Casado J (2021) Characterization of Pelvic Floor Activity in Healthy Subjects and with Chronic Pelvic Pain: Diagnostic Potential of Surface Electromyography. Sens (Basel) 21(6):2225. 10.3390/s21062225 Juganavar A, Joshi KS (2022) Chronic Pelvic Pain: A Comprehensive Review. Cureus 14(10):e30691. 10.7759/cureus.30691 Greiner M, Dadon M, Lemasle P, Cluzel P (2012) How does the pathophysiology influence the treatment of pelvic congestion syndrome and is the result long-lasting? Phlebology 27(Suppl 1):58–64. 10.1258/phleb.2011.012s07 Neuenschwander J, Sebastian T, Barco S, Spirk D, Kucher N (2022) A novel management strategy for treatment of pelvic venous disorders utilizing a clinical screening score and non-invasive imaging. Vasa 51(3):182–189. 10.1024/0301-1526/a001001 Tessari L, Cavezzi A, Frullini A (2001) Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 27(1):58–60 Filippiadis DK, Binkert C, Pellerin O, Hoffmann RT, Krajina A, Pereira PL (2017) Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System. Cardiovasc InterventRadiol 40(8):1141–1146. 10.1007/s00270-017-1703-4 Kashef E, Evans E, Patel N, Agrawal D, Hemingway AP (2023) Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options. CVIR Endovasc 6(1):25. 10.1186/s42155-023-00365-y Marcelin C, Le Bras Y, Molina Andreo I, Jambon E, Grenier N (2022) Diagnosis and Management of Pelvic Venous Disorders in Females. Diagnostics (Basel) 12(10):2337. 10.3390/diagnostics12102337 Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim MD, Nicolini PH, Pabon-Ramos WM, Rosenblatt M (2021) The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. Phlebology 36(5):342–360. 10.1177/0268355521999559 Park SJ, Lim JW, Ko YT, Lee DH, Yoon Y, Oh JH, Huh CY (2004) Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. Am J Roentgenol 182(3):683–688. doi: 0.2214/ajr.182.3.1820683 Asciutto G, Mumme A, Marpe B, Köster O, Asciutto KC, Geier B (2008) MR venography in the detection of pelvic venous congestion. Eur J VascEndovasc Surg 36(4):491–496. 10.1016/j.ejvs.2008.06.024 Freedman J, Ganeshan A, Crowe PM (2010) Pelvic congestion syndrome: therole of interventional radiology in the treatment of chronic pelvic pain. Postgrad Med J 86(1022):704–710. 10.1136/pgmj.2010.099473 Farquhar CM, Rogers V, Franks S, Beard RW, Wadsworth J, Pearce S (1989) A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol 96(10):1153–1162. 10.1111/j.1471-0528.1989.tb03190.x Knuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W (2015) Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeuticissues. Am J Roentgenol 204(2):448–458. 10.2214/AJR.14.12709 Gargiulo T, Mais V, Brokaj L, Cossu E, Melis GB (2003) Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestionsyndrome. J Am Assoc GynecolLaparosc 10(4):501–504. 10.1016/s1074-3804(05)60156-9; Drife JO (1993) The pelvic pain syndrome. Br J ObstetGynaecol 100(6):508–510. 10.1111/j.1471-0528.1993.tb15297.x Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH, Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW, Society for Vascular Surgery; American Venous Forum (2011) The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 53(5 Suppl):2S–48S. 10.1016/j.jvs.2011.01.079 Mahmoud O, Vikatmaa P, Aho P, Halmesmäki K, Albäck A, Rahkola-Soisalo P, Lappalainen K, Venermo M (2016) Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous LymphatDisord 4(3):355–370. 10.1016/j.jvsv.2016.01.002 Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP (2016) The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 20(5):1–108. 10.3310/hta20050 Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Minor revision 25 Jan, 2024 Reviewers agreed at journal 03 Jan, 2024 Reviewers invited by journal 31 Dec, 2023 Editor assigned by journal 27 Dec, 2023 First submitted to journal 26 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3809569","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264549839,"identity":"82b94eae-8da6-4572-a26a-e31719717cdc","order_by":0,"name":"Fabio Corvino","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDAC5oMPwDQbAwMjiMXDR1ALW7IBTAsziMXDRrQWEFMCqhc/4GdjZnzwo+JeYp9087HKrzl2MmwMzA8f3cCjRbKNmdmw50xxYpvMsbTbstuSgQ5jMzbOwaPF4H7/MWnGtgRjNokcs9uS25iBWnjYpPFpsT/GzP4bpqVYcls9YS0GbMxA37QlyIG0MH7cdpiwFoljzMySPWdAWtKSpRm3HecBmoHfL/xtzIwfflQk8MjPSD748ee2ant+9uaHj/FpQQHMPGCSWOUgwPiDFNWjYBSMglEwYgAAXxk7UMbpfQMAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-2593-8148","institution":"Azienda Ospedaliera Antonio Cardarelli","correspondingAuthor":true,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Corvino","suffix":""},{"id":264549840,"identity":"d75297cc-f1e9-4f0a-a673-4d2a201ec1b0","order_by":1,"name":"Francesco Giurazza","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Giurazza","suffix":""},{"id":264549841,"identity":"0aa19bd8-4a8c-4ed5-baa7-49cfc25bb032","order_by":2,"name":"Milena Coppola","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Milena","middleName":"","lastName":"Coppola","suffix":""},{"id":264549842,"identity":"34714aeb-ab99-4fbe-8d69-e1462fc7891c","order_by":3,"name":"Antonio Tomasello","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Tomasello","suffix":""},{"id":264549843,"identity":"acd098e1-a0bd-4ed3-a31f-d86a56daf205","order_by":4,"name":"Francesco Coletta","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Coletta","suffix":""},{"id":264549844,"identity":"e99c6bf8-38c6-4afb-be1a-e45177e91274","order_by":5,"name":"Crescenzo Sala","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Crescenzo","middleName":"","lastName":"Sala","suffix":""},{"id":264549845,"identity":"b4f55a04-3883-417a-a269-db24c8746d8e","order_by":6,"name":"Bernardo Maria de Martino","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Bernardo","middleName":"Maria","lastName":"de Martino","suffix":""},{"id":264549846,"identity":"73237c4a-1e25-4c2d-8ace-f9fd9a63d3b3","order_by":7,"name":"Antonio corvino","email":"","orcid":"","institution":"UniParthenope: Universita degli Studi di Napoli Parthenope","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"corvino","suffix":""},{"id":264549847,"identity":"0c7c6606-0439-41af-ae64-9acea04e9fcc","order_by":8,"name":"Raffaella Niola","email":"","orcid":"","institution":"Cardarelli Hospital: Ospedale Cardarelli","correspondingAuthor":false,"prefix":"","firstName":"Raffaella","middleName":"","lastName":"Niola","suffix":""}],"badges":[],"createdAt":"2023-12-26 20:59:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3809569/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3809569/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49129955,"identity":"ce380a20-772b-4c01-ab7d-55f8c281d844","added_by":"auto","created_at":"2024-01-03 15:22:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225469,"visible":true,"origin":"","legend":"\u003cp\u003eElectrodes location for the PFM sEMG study.\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-3809569/v1/7cfb794412f12a26619217fc.png"},{"id":49129315,"identity":"90d2cd4a-ea50-468d-9e0a-1463263c1824","added_by":"auto","created_at":"2024-01-03 15:14:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4612773,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ea\u003c/em\u003e: T1 water-Lava axial MRI scan shows periuterine plexus bilaterally dilatated with tortuous course and a maximum caliber of 6 mm. (white-arrow). \u003cem\u003eb-c\u003c/em\u003e: Selective and superselective diagnostic phlebography through a 5 Fr catheter demonstrates ovarian vein dilation with reflux in the para-uterine veins and partially drainage in internal iliac veins. \u003cem\u003ed:\u003c/em\u003e Final image after sclero-embolization procedure.\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-3809569/v1/0db7fd4ecf248b0214818a2e.png"},{"id":49130186,"identity":"2b30c37d-53b6-46da-8e05-749fd8f311ef","added_by":"auto","created_at":"2024-01-03 15:30:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1496783,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3809569/v1/9ac73f40-63cf-4c1e-910a-e3a0fc1a0113.pdf"}],"financialInterests":"","formattedTitle":"Chronic pelvic pain in congestion pelvic syndrome: clinical impact and electromyography pelvic floor activity prior and after endovascular treatment","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eChronic pelvic pain (CPP) is a complex and disabling clinical condition among women of childbearing age; about one-quarter of women in reproductive age complain this clinical condition of greater one year in duration. The clinical symptoms are generally vague and inconsistent reflecting the multiple factors that have a role in its pathogenesis. The American College of Obstetricians and Gynaecologist define CPP as \u0026ldquo;pain of the pelvic region, sensed from the pelvic organs themselves that typically last more than 6 months\u0026rdquo;. Musculoskeletal, neurological and psychological conditions have been implicated in presentations of pelvic pain, but no diagnosis is made in over 60% of cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 1948 Taylor firstly proposed a connection between the presence of pelvic varicosities and CPP [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]; this condition was classified as clinical entity, known as pelvic congestion syndrome (PCS), only after Beard et al. work of the 1980s, in which more than 90% of women with CPP presented in association pelvic varicosities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, more recent report described a prevalence of 39% of women with CPP and about 30% of these patients have a pelvic venous insufficiency related to PCS [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePCS is one of the main causes of CPP, accounting about 30% of these patients have a pelvic venous insufficiency. The pathophysiology of PCS pain includes the array of visceral, somatic and neurological pain generator [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In chronic lower extremities venous insufficiency, the pain state is related to abnormal vessel function [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; Kaupilla 73 et al., about 4 decades ago, in a group of PCS patients affected by CPP demonstrated a higher rate of histological vascular anomalies (such as fibrosis, muscular hypertrophy and widened ovarian diameter) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, more recent views of pain states emphasize both peripheral and central contributors to nociception. Indeed, in some male affected by chronic pelvic pain, the presence of periprostatic pelvic varices have been described, suggesting a relationship between autonomic nervous system dysregulation of venous tone and some pelvic pain states [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; similarly, the cerebral vasodilation seen in migraine headaches is thought to reflect neurological changes of the trigeminal system [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA correlation between CPP and dysfunction of the pelvic floor musculature (PFM) has been demonstrated; surface electromyography (sEMG) seems to be a useful tool to evaluate this kind of dysfunctions.\u003c/p\u003e \u003cp\u003eCPP are closely associated with dysfunction of the PFM and the sEMG turned out to be a useful tool to assess this kind of patients. sEMG is the electric signal recorded by means of electrodes attached to the surface of the skin produced by the sum of the extracellular potentials from the active muscle fibers beneath the electrodes. A greater power of the PFM activity has been demonstrated in CPP patients than in healthy women, especially when compared with mature/parous subjects; this difference is related to an increased number of motor units recruited and the muscle fatigue caused by overactivation of the PFM [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of our retrospective observational study is to analyze the clinical impact of endovascular treatment in CPP patients due to PCS and to assess the diagnostic value of sEMG study of PFM in PCS patients pre- and post-endovascular treatment.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e \u003cem\u003ePatients.\u003c/em\u003e Between January 2019 and July 2023, 32 consecutive patients (mean age, 38 years; 29\u0026ndash;60) with clinical diagnosis of CPP due to type 1 Greiner\u0026rsquo;s classification PCS underwent endovascular treatment in a major hospital of an Italian metropolitan city [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. An Excel database was prospectively recorded and retrospectively analyzed. Data was collected from medical report, discharge letters and endovascular procedure report, including demographic information, relevant comorbidities and symptoms. Moreover, a clinical score, derived from a previously manuscript, was used to diagnose PCS and to evaluate clinical improvement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The main demographic and clinical characteristics of patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMain demographic and clinical characteristics of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of pregnancies, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine myomas, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometriosis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaricosis vein, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (56.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic cysts, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep vein thrombosis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcquisite Arteriovenous Malformation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e26 (81.2%) of 32 patients had previous pregnancies (mean number of deliveries:2; 1\u0026ndash;3) and only 2 had previous history of endometriosis treated with laparoscopic surgery in 1 case and with hormones in both cases. The most prevalent symptoms were CPP (100% of patients), dysmenorrhea (75%), post-coital pain (68.7%), dyspareunia (50%) and leg varicosities (48.8%) \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. A pre-procedural Magnetic Resonance Imaging (MRI) imaging was performed in all patients to exclude the presence of a PCS related to a nutcracker syndrome, a May-Thurner one or other secondary causes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSymptoms and PCS score at baseline of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic lower abdominal pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysmenorrhea, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostcoital pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (68.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg varicosities, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (48.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVulvar varicosities, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthostatic pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (31.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspareunia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBack pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhoids, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysuria, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCS score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e This study was approved by the local ethic committee and was conducted according to the Declaration of Helsinki principles. The human ethics review board at our institution approved the study design. Informed consent for data collection was obtained from all conscious patients. To characterize PFM activity a sEMG was carried out at baseline prior endovascular treatment and 6 months after it. The latency of the P40 response (n.v. 37.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.60 msec), the P1-N1 amplitude (n.v.119 3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u0026micro;V) and the latency of the R1 early response (n.v.\u0026lt;45 msec) were evaluated in the paraclitoral site \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Contraindications to procedure include active pelvic infection, severe contrast medium allergy, coagulopathy and pregnancy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eEndovascular technique.\u003c/em\u003e The procedure was undertaken in inpatient condition with mild analgosedation. Bilateral ovarian and iliac diagnostic subtraction phlebography was performed from femoral access to delineate the anatomy and identify the main vessels and collateral pathway, obtained with and without provocation such as Valsalva maneuver. Ovarian catheterization was achieved with a 5 Fr HET or another shaped tip catheter (COOK Medical, Bloomington, IN, USA) with a 0.038\u0026rdquo; lumen due to type of the coils utilized. In case where 0.018\u0026rdquo; micro-coils platform was utilized a 2.7 Fr Progreat Terumo (Terumo Medical, Tokyo, Japan) was used to delivery. A sandwich technique was preferred in all cases with pushable coils used after distal injection of 3% sodium tetradecyl sulphate (STS), prepared as a foam according to the Tessari method, with a maximum dose per procedure as 10 ml [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The complete occlusion with of the entire length of incompetent vein prevent possible future recanalization. Coils common sizes used range from 8 mm to 20 mm, generally oversized to prevent migration. Internal iliac veins were embolized with the same sandwich technique in cases where a venous reflux was confirmed at phlebography during Valsalva maneuver. Final phlebography control after embolization is undertaken to confirm vessel occlusion. In patients with symptomatic uterine myomas, a bilateral uterine artery embolization (UAE) was carried out in the same session. All procedures were performed by an interventional radiology radiologist with more than 5 years of experience. The primary cause of PCS was ovarian vein reflux highlighted in 29 patients (90.6%) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e and internal iliac vein reflux in 1 patient (3.2%); in 3 patients (9.3%) phlebography demonstrated a combination of both. Ovarian vein embolization was performed in 28 patients (87.5%) and iliac vein embolization in 2 patients (6.25%). Findings from pelvic phlebography with fluoroscopy and therapeutic details are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic and procedural data of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhlebographic findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian vein reflux, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (90.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal vein reflux, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (34.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVulvar vein reflux\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain pathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian vein insufficiency, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (87.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal iliac vein insufficiency, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOvarian vein embolization, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (87.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInternal iliac vein embolization, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003esEMG signal Recording Technique.\u003c/em\u003e sEMG signal was recorded in each patient from the left and right sides of the pelvic floor in a dorsal lithotomy position with adhesive electrodes. The study of the sacral evoked potentials was carried out with a manual bipolar stimulator with cathode in the paraclitoral site and recording using surface electrodes in the parietal region CZ (-2 cm) \u0026ndash; FPZ according to the international 10\u0026ndash;20 system, with square wave stimulation of the duration of 0.5 msec, intensity 3\u0026ndash;4 times the sensory threshold, frequency 1.5 Hz, 151 impedance\u0026thinsp;\u0026lt;\u0026thinsp;5 kOhm, bandwidth 1 Hz-3 kHz, 200 stimuli. The latency of the P40 response (n.v. 37.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.60 msec) and the P1-N1 amplitude (n.v. 3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u0026micro;V) were evaluated. The anal pudendal reflex was evaluated with a manual bipolar stimulator with the cathode positioned in the paraclitoral site and recording by means of coaxial needle electrodes from the external anal sphincter muscle. The latency of the R1 early response was evaluated (n.v.\u0026lt;45 msec).\u003c/p\u003e \u003cp\u003e \u003cem\u003eStudy endpoints and definition.\u003c/em\u003e \u003cb\u003ePrimary clinical success\u003c/b\u003e was defined as the change in symptoms severity following 6-months endovascular therapy. Symptoms relief was divided in three categories relating to its improvement: 1. Complete freedom from PCS symptoms; 2. Improvement with residual symptoms; 3. No improvement or changes of symptoms.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary clinical outcome\u003c/b\u003e was defined as a difference in the sEMG study between the single parameters studied before and after endovascular treatment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTechnical success\u003c/b\u003e was defined as the successful endovascular procedure with no further evidence at imaging of reflux.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSafety outcome\u003c/b\u003e was defined as the prevalence of peri and post-operative complications, categorized according to CIRSE guidelines [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eFollow-up and clinical outcome.\u003c/em\u003e Median follow-up was 8 months (range 6\u0026ndash;10 months). Clinical improvement was demonstrated in 29 patients (90%) with 15 patients (46%) having complete resolution of symptoms. In 3 patients (9.3%), endovascular treatment did not improve symptoms. One patient had history of endometriosis with previous multiple surgical laparoscopic interventions. The second one had previous history of sacral trauma with associated a significant increase of R1 latency of the anal pudendal reflex, directly related with a neuronal impairment. The last one had previous history of urolithiasis with different previous urological procedure. In one case with no resolution of vulvar varices after ovarian sclero-embolization, the patient underwent to direct percutaneous STS foam sclerotherapy with complete resolution. The latency values of P40 response pre-treatment are slight reduced compared to normal value; compared to pre-treatment value, the latency of P40 response was slight increased after treatment but not with a statistical significance. An increase of P1-N1 signal amplitude in PCS was demonstrated; moreover, a reduction of signal amplitude after PCS treatment was demonstrated but with no statistical significance. There was no statistically difference before and after endovascular treatment in study of R1 latency of the anal pudendal reflex. The sEMG values pre and after embolization are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Complications due to endovascular procedure occurred in 4 patients (12.5%): in 2 patient (6.25%) partial coil migration into inferior vena cava in one patient and in left renal vein in another one was promptly retrieved by snaring techniques during endovascular procedure (Grade 1 CIRSE classification); 2 patient (6.25%) suffered mild symptoms of pelvic thrombophlebitis successfully treated with low molecular weight heparin (LMWH) (Grade 3 CIRSE Classification).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe sEMG values evaluated pre- and after- PCS sclero-embolization.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003esEMG signals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-embolization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter embolization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatency p40 response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40 msec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30 msec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1-N1 amplitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96 \u0026micro;V\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85 \u0026micro;V\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnal pudendal reflex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026thinsp;\u0026plusmn;\u0026thinsp;2 msec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u0026thinsp;\u0026plusmn;\u0026thinsp;3 msec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCPP has a worldwide population prevalence of 15% in female population between 18 and 50 years and in 61% of cases the etiology is unexplained. Labeling pelvic pain patients with single pathologic diagnoses such as PCS may hinder treatment efforts; however, a prevalence estimated around 30% of PCS in CPP patients has been demonstrated [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathogenesis of PCS is still unclear, but it has been demonstrated its multifactorial nature. Pregnancy hyper flow venous condition, in terms of gonadal and pelvic plexus dilated, due to estrogen level vasodilator effects could one of the pathogenetic factor involved. A main role, in addition, is related to a valve incompetence development and/or stenosis/obstruction onset of the draining veins [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The type 1 Greiner\u0026rsquo;s classification PCS treated in our study, that is a non-obstructive left ovarian vein insufficiency and reflux, is the most common pathophysiological cause with a prevalence of more than 50% of cases. In 2021 Meissner et al. proposed the Symptoms-Varices-Pathophysiology (SVP) classification of pelvic venous disorders: however, its effective role in determining treatment has still to be demonstrated [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A novel PCS management strategy proposed an association between a simple screening tool - the PCS score - that gynecologists and primary care physicians could use, and an accurate noninvasive imaging; this synergy, also used in our study, seems to improve the PCS diagnosis and successful rate treatment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA non-invasive imaging study is mandatory in PCS management strategy, primarily to confirm the clinical suspect of PCS and secondly to exclude other CPP causes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Ultrasound (US), both transabdominal and transvaginal, with colour Doppler imaging and Doppler spectral analysis should be used in PCS diagnosis. A dilated and tortuous pelvic vein (diameter\u0026thinsp;\u0026gt;\u0026thinsp;6 mm), a slow blood flow (\u0026lt;\u0026thinsp;3cm/s) or reversal caudal flow, a dilated arcuate veins and polycystic changes in the ovaries are the ultrasound diagnostic criteria for PCS diagnosis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. MRI represent the first line of investigation, providing better imaging of the many causes of CPP and, due to the patient young age, should be preferred to Computed Tomography (CT) given the absence of ionizing radiation. MRI has shown a sensitivity and specificity of 88% and 67%, respectively, in demonstration of ovarian veins congestion. However, CT and MRI studies are both performed in supine position, thus being able to underestimate venous dilation compared to US and phlebography where provocative maneuvers could be employed. In our cases, a prior MRI study with demonstration of pelvic venous congestion for ovarian veins and MR angiography sequence with detection of vein dilatation and reflux was mandatory [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Catheter phlebography still remains the gold standard for PCS diagnosis, but its diagnostic role is reserved only in cases when noninvasive studies are inconclusive [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePCS treatments proposed and used in time are multiple and include conservative, psychological, medical, surgical and endovascular options, both in isolation and in combination. An RCT comparing combined hormone suppression and psychotherapy experienced sustained CPP relief with a\u0026thinsp;\u0026gt;\u0026thinsp;50% reduction 262 in pain score [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A medical therapy, alone or in combination with other treatment, didn\u0026rsquo;t demonstrated a superior efficacy than another but only an increase of adverse symptoms if used in a long-term setting [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Surgical treatments include different alternatives including a mini-invasive laparoscopic approach for ovarian veins ligation to a more invasive one as hysterectomy and/or oophorectomy. Only one study published by Gargiulo et al. demonstrated an extraordinary 100% symptoms relief in 23 women treated with a laparoscopic ovarian vein ligation treatment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Finally, hysterectomy, proposed when all other treatments have failed, showed a 22\u0026ndash;33% of failure rate in clinical symptoms resolution [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEndovascular management of PCS is recommended with a level 2B evidence by the Society of Vascular Surgery: \u0026ldquo;We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or trans-catheter sclerotherapy, used alone or together\u0026rdquo; [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Our study confirms the actual literature about the difference rate between technical success (almost always described above 95%) and clinical success (usually between 58% and 100%), regardless of the embolic agent. To date, there have not been any randomized study comparing clinical success using different embolic agents for PCS endovascular treatment. The choice of embolic agent is generally operator dependent with no different outcome described with use of a specific agent [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Moreover, such a high technical success with a low complication rate allows us to conclude that endovascular techniques are safe and effective in PCS syndrome tretment.\u003c/p\u003e \u003cp\u003eClinical outcome is in line with previous literature and it could be considered as overall positive. 90% of patients showed a clinical improvement with 46% of patients having complete resolution of symptoms; in only 3 patients (9.3%), endovascular treatment did not improve symptoms. A recent meta-analysis demonstrated a short-term outcome similar to our study, showing a clinical improvement in 88% of patients and a 6\u0026ndash;32% of patients that not experienced any symptom relief [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Another comprehensive review in 2018 stated that of the 1308 patients included in the study about 75% reported an early symptoms relief after embolization [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCPP and other clinical condition of the pelvic floor (i.e., fecal incontinence, organ prolapse, etc\u0026hellip;) are closely associated with disfunction of the pelvic floor musculature PFM, so that sEMG could be a useful tool to assess patients\u0026rsquo; clinical conditions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our study, the baseline value of the latency of p40 response and P1-N1 signal amplitude confirm that a slight muscular hypertonia is associated with CPP due to PCS; however, these values after PCS endovascular treatment point out that this correlation, is not directly connected with venous insufficiency, but there are subtle other pathologies related that should be studied further. The R1 latency of the anal reflex comparison show no difference between pre and after treatment; this type of evaluation is directly related with neuronal impairment that is highlighted in only one patient. The results obtained prove that sEMG can reveal alterations in the PFM electrophysiology associated with CPP related to PCS and provide clinicians with objective information that can help them to better evaluate CPP patients\u0026rsquo; condition, thus allowing more efficient management of this complex syndrome. Future studies of PCS-related pelvic pain should also evaluate central mediators of vascular tone, perhaps by employing biofeedback or stress reduction. Anxiety and depression in this group of women has long been recognized with much debate as to whether this cause or effect. Farquhar et al. postulated that in a population of PCS patients, only women on combined hormone suppression and psychotherapy experienced sustained CPP relief, pointing out that overlapping neurological and hormonal factors can influence pain symptom expression [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEven though the sample size was homogenous, our study has several limitations. First, the sample size studied was small. Second, the evaluation only of patients with a type 1 Greiner\u0026rsquo;s classification PCS, makes the population more homogeneous, ruling out patients with type 2 and 3 of PCS syndrome, that asses more than 40% of patients with PCS. Third, all patients were recruited by only one interventional radiology center that could bring a selection bias. Last, the absence of a comparison healthy population studied with sEMG. However, given the absence in literature of a randomized controlled trials on management and treatment strategy of PCS with also sEMG study of PFM, our data may provide a reference for a future trial.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eCurrently, the management of women with chronic pelvic pain is suboptimal, with only 40% of affected women being referred to a dedicated specialist. Endovascular therapy should be chosen over a less effective medical (psychotropic, hormonal or venoactive drugs) and a more invasive surgical approach, highlighting that PCS is a multifactorial disease where vein disease is only one side of a more complex pathology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The slight differences found between PFM activity in PCS patients prior and after endovascular treatment prove that sEMG could be a useful tool for a selected patients and more studies are necessary for identify its role in CPP clinical diagnosis and management.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cul\u003e\n \u003cli\u003eThis study was performed in line with the principles of the Declaration of Helsinki;\u003c/li\u003e\n \u003cli\u003eAll human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments;\u003c/li\u003e\n \u003cli\u003eInformed consent was obtained from all individual participants included in the study;\u003c/li\u003e\n \u003cli\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request;\u003c/li\u003e\n \u003cli\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript;\u003c/li\u003e\n \u003cli\u003eThe authors have no relevant financial or non-financial interests to disclose;\u003c/li\u003e\n \u003cli\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by G. F., C. M., N. R.. The first draft of the manuscript was written by C. F. and C. A. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript;\u003c/li\u003e\n \u003cli\u003eThe authors declare that they have no conflict of interest.\u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiddle AD, Davies AH (2007) Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology 22(3):100\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1258/026835507780807248\u003c/span\u003e\u003cspan address=\"10.1258/026835507780807248\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor HC Jr (1949) Vascular congestion and hyperaemia: their effect on structure and function in the female reproductivesystem. Am J ObstetGynaecol 57:211\u0026ndash;278\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeard RW, Highman JH, Pearce S, Reginald PW (1984) Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet ii:946\u0026ndash;949\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC (2006) Embolotherapy for pelvic congestion syndrome: long-term results. J VascIntervRadiol 17:289\u0026ndash;297. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.RVI.0000194870.11980.F8\u003c/span\u003e\u003cspan address=\"10.1097/01.RVI.0000194870.11980.F8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown CL, Rizer M, Alexander R, Sharpe EE 3rd, Rochon PJ (2018) Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin InterventRadiol 35(1):35\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0038-1636519\u003c/span\u003e\u003cspan address=\"10.1055/s-0038-1636519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoward FM (2003) Chronic pelvic pain. Obstet Gynecol 101(3):594\u0026ndash;611. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0029-7844(02)02723-0\u003c/span\u003e\u003cspan address=\"10.1016/s0029-7844(02)02723-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicolaides AN (2003 Jul-Aug) From symptoms to leg edema: efficacy of Daflon 500 mg. Angiology 54(Suppl 1):S33\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0003319703054001S05\u003c/span\u003e\u003cspan address=\"10.1177/0003319703054001S05\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKauppila A (1970) Uterine phlebography with venous compression. A clinical and roentgenological study. Acta ObstetGynecolScand Suppl 3(Suppl 3):1\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/00016347009155062\u003c/span\u003e\u003cspan address=\"10.3109/00016347009155062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerasaki T, Watanabe H, Saitoh M, Uchida M, Okamura S, Shimizu K (1995) Magnetic resonance angiography in prostatodynia. Eur Urol 27(4):280\u0026ndash;285. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000475181\u003c/span\u003e\u003cspan address=\"10.1159/000475181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW (1989) A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J ObstetGynaecol 96(10):1153\u0026ndash;1162. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1471-0528.1989.tb03190.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.1989.tb03190.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbaladejo-Belmonte M, Tarazona-Motes M, Nohales-Alfonso FJ, De-Arriba M, Alberola-Rubio J, Garcia-Casado J (2021) Characterization of Pelvic Floor Activity in Healthy Subjects and with Chronic Pelvic Pain: Diagnostic Potential of Surface Electromyography. Sens (Basel) 21(6):2225. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/s21062225\u003c/span\u003e\u003cspan address=\"10.3390/s21062225\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJuganavar A, Joshi KS (2022) Chronic Pelvic Pain: A Comprehensive Review. Cureus 14(10):e30691. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.30691\u003c/span\u003e\u003cspan address=\"10.7759/cureus.30691\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreiner M, Dadon M, Lemasle P, Cluzel P (2012) How does the pathophysiology influence the treatment of pelvic congestion syndrome and is the result long-lasting? Phlebology 27(Suppl 1):58\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1258/phleb.2011.012s07\u003c/span\u003e\u003cspan address=\"10.1258/phleb.2011.012s07\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeuenschwander J, Sebastian T, Barco S, Spirk D, Kucher N (2022) A novel management strategy for treatment of pelvic venous disorders utilizing a clinical screening score and non-invasive imaging. Vasa 51(3):182\u0026ndash;189. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1024/0301-1526/a001001\u003c/span\u003e\u003cspan address=\"10.1024/0301-1526/a001001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTessari L, Cavezzi A, Frullini A (2001) Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 27(1):58\u0026ndash;60\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFilippiadis DK, Binkert C, Pellerin O, Hoffmann RT, Krajina A, Pereira PL (2017) Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System. Cardiovasc InterventRadiol 40(8):1141\u0026ndash;1146. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00270-017-1703-4\u003c/span\u003e\u003cspan address=\"10.1007/s00270-017-1703-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKashef E, Evans E, Patel N, Agrawal D, Hemingway AP (2023) Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options. CVIR Endovasc 6(1):25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s42155-023-00365-y\u003c/span\u003e\u003cspan address=\"10.1186/s42155-023-00365-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcelin C, Le Bras Y, Molina Andreo I, Jambon E, Grenier N (2022) Diagnosis and Management of Pelvic Venous Disorders in Females. Diagnostics (Basel) 12(10):2337. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/diagnostics12102337\u003c/span\u003e\u003cspan address=\"10.3390/diagnostics12102337\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M, Learman LA, Atashroo D, Lurie F, Passman MA, Basile A, Lazarshvilli Z, Lohr J, Kim MD, Nicolini PH, Pabon-Ramos WM, Rosenblatt M (2021) The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein \u0026amp; Lymphatic Society International Working Group on Pelvic Venous Disorders. Phlebology 36(5):342\u0026ndash;360. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0268355521999559\u003c/span\u003e\u003cspan address=\"10.1177/0268355521999559\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark SJ, Lim JW, Ko YT, Lee DH, Yoon Y, Oh JH, Huh CY (2004) Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. Am J Roentgenol 182(3):683\u0026ndash;688. doi: 0.2214/ajr.182.3.1820683\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsciutto G, Mumme A, Marpe B, K\u0026ouml;ster O, Asciutto KC, Geier B (2008) MR venography in the detection of pelvic venous congestion. Eur J VascEndovasc Surg 36(4):491\u0026ndash;496. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejvs.2008.06.024\u003c/span\u003e\u003cspan address=\"10.1016/j.ejvs.2008.06.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreedman J, Ganeshan A, Crowe PM (2010) Pelvic congestion syndrome: therole of interventional radiology in the treatment of chronic pelvic pain. Postgrad Med J 86(1022):704\u0026ndash;710. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/pgmj.2010.099473\u003c/span\u003e\u003cspan address=\"10.1136/pgmj.2010.099473\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarquhar CM, Rogers V, Franks S, Beard RW, Wadsworth J, Pearce S (1989) A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol 96(10):1153\u0026ndash;1162. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1471-0528.1989.tb03190.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.1989.tb03190.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W (2015) Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeuticissues. Am J Roentgenol 204(2):448\u0026ndash;458. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2214/AJR.14.12709\u003c/span\u003e\u003cspan address=\"10.2214/AJR.14.12709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGargiulo T, Mais V, Brokaj L, Cossu E, Melis GB (2003) Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestionsyndrome. J Am Assoc GynecolLaparosc 10(4):501\u0026ndash;504. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s1074-3804(05)60156-9;\u003c/span\u003e\u003cspan address=\"10.1016/s1074-3804(05)60156-9;\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrife JO (1993) The pelvic pain syndrome. Br J ObstetGynaecol 100(6):508\u0026ndash;510. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1471-0528.1993.tb15297.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.1993.tb15297.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH, Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW, Society for Vascular Surgery; American Venous Forum (2011) The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 53(5 Suppl):2S\u0026ndash;48S. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvs.2011.01.079\u003c/span\u003e\u003cspan address=\"10.1016/j.jvs.2011.01.079\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmoud O, Vikatmaa P, Aho P, Halmesm\u0026auml;ki K, Alb\u0026auml;ck A, Rahkola-Soisalo P, Lappalainen K, Venermo M (2016) Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous LymphatDisord 4(3):355\u0026ndash;370. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvsv.2016.01.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jvsv.2016.01.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChampaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP (2016) The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 20(5):1\u0026ndash;108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3310/hta20050\u003c/span\u003e\u003cspan address=\"10.3310/hta20050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sclero-embolization, Chronic pelvic pain, Congestion pelvic syndrome, Electromyography, Pelvic floor activity","lastPublishedDoi":"10.21203/rs.3.rs-3809569/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3809569/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo characterize clinical impact of endovascular treatment in Chronic Pelvic Pain (CPP) patients due to Pelvic Congestion Syndrome (PCS) and to assess the diagnostic value of surface electromyography (sEMG) study of pelvic floor musculature (PFM) in PCS patients pre- and post-endovascular treatment. Between January 2019 and July 2023, we studied consecutive patients who were referred for interventional radiology assessment and treatment to a tertiary trauma care Hospital, had evidence of non-obstructive PCS by Magnetic Resonance Imaging (MRI), had performed a sEMG of PFM and underwent endovascular treatment. The primary outcome was clinical, defined as change in symptoms severity after endovascular treatment. The secondary outcome was a difference in the sEMG values pre- and after endovascular therapy.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe included 32 women (mean age 38 years). CPP was the leading symptom in 100% patients, followed by dysmenorrhea (75%) and post-coital pain (68.7%). Endovascular therapy included ovarian vein embolization in 28 patients (87.5%) and internal iliac vein embolization in only 2 patients (6.2%). After a median of 8 (range 6\u0026ndash;10) months from endovascular treatment, 29 (90%) of patients reported improvement of the main symptoms, and 15 (46%) were symptom-free. The sEMG values didn\u0026rsquo;t show a statistical difference pre- and after PCS endovascular treatment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEndovascular treatment appeared to be highly effective in CPP due to PCS and was associated with a low rate of complication. sEMG study could be useful in revealing alteration of PFM electrophysiology, but a difference pre and after embolization in PCS patient wasn\u0026rsquo;t demonstrated.\u003c/p\u003e","manuscriptTitle":"Chronic pelvic pain in congestion pelvic syndrome: clinical impact and electromyography pelvic floor activity prior and after endovascular treatment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 15:14:04","doi":"10.21203/rs.3.rs-3809569/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2024-01-26T04:04:32+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-01-03T14:47:59+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-12-31T12:51:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-28T04:24:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2023-12-26T12:07:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9f90d322-a1ef-4a7b-8b07-ecb603939f1a","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-01-31T06:00:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 15:14:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3809569","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3809569","identity":"rs-3809569","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}