The usefulness of transvaginal ultrasonography in the diagnosis of pelvic venous disorders.

Pelvic venography was performed in 195 of 197 patients who met the above-mentioned criteria for PeVD. Venography was not performed in one patient with symptomatic SARS-CoV-2 infection and in one patient in whom left ovarian vein thrombosis was detected during the TVUS examination. Of the 195 patients in whom the TVUS revealed the presence of at least one parameter characteristic for PeVD, pelvic venography confirmed the TVUS findings in 187 (95.9%). During TVUS, the presence of dilatation of ovarian veins (cut-off diameter value > 8 mm) was observed accordingly: unilaterally in 44 and bilaterally in 5 patients. In all 49 patients with ovarian vein dilatation, venography confirmed the TVUS findings. Low blood flow (cut-off velocity < 3 cm/s) in ovarian veins was detected by TVUS unilaterally in 55 and bilaterally in 99 patients. Of these 154 patients, venography confirmed the low blood flow in 148 patients (96.1%). Reflux in ovarian veins (cut-off time > 1 s) was observed by TVUS unilaterally in 43 and bilaterally in 38 patients. In this group of 81 patients, venography confirmed the presence of reflux in 79 patients (97.5%). Dilatation of arcuate veins within the myometrium communicating to pelvic varicosities was detected by TVUS in 137 patients. In 132 patients (96.4%), venography confirmed this finding. Pelvic venography confirmed the PeVD in 94.5% of patients with one positive ultrasound parameter, 95.1% with two positive ultrasound parameters, 96.4% with three positive ultrasound parameters, and 100% with four positive ultrasound parameters. There was no statistically significant difference between the age and BMI of the patients and the diagnostic effectiveness of any of the ultrasound parameters (Fig.  7 ). Fig. 7 Study group design characteristics. Study group design characteristics.

This observational cross-sectional study included 197 patients hospitalized due to the typical symptoms of PeVD listed above between September 2022 and April 2024. A detailed medical interview was conducted with each patient – the patients also received a standardized questionnaire form regarding their symptoms and medical history. Each patient, in the period preceding hospitalization, was subjected to at least six months of pharmacological treatment (venoactive drugs) and lifestyle change (body mass reduction, smoking cessation, personalized physical activity). None of the patients included in the study had been diagnosed with PeVD by venography previously. Other exclusion criteria included the presence or serious suspicion of endometriosis, adenomyosis, uterine fibroids, and adnexal lesions based on the symptoms, surgical and medical history and TVUS examination performed using prepared protocol as well as medical interview 20 , 21 . Patients with cyclic pain and pregnant women were also excluded. Following this, a gynaecological examination and TVUS were performed. TVUS was performed independently by 4 examiners (F.S. − 500 examinations (33.6%), P.R.M. − 550 examinations (35.4%), P.S. − 2450 examinations (16.9%), S.W. − 2550 examinations (14.1%) using a Samsung Hera W10 with a 4.6 MHz transvaginal probe. Each sonographer examined patients according to the same specially prepared protocol. In addition to the typical assessment of female pelvic anatomy, to evaluate patients with symptoms of PeVD, four parameters were assessed: the presence of dilatation of ovarian veins (cut-off diameter > 8 mm), low blood flow (cut-off velocity  1 s) and dilatation of arcuate veins within the myometrium communicating to pelvic varicosities 18 , 22 , 23 (Figs.  1 , 2 , 3 , 4 ). Fig. 1 TVUS examination of a 37-year-old woman with typical PeVD symptoms: dilated left ovarian vein (diameter of 9 mm) (arrows) ( A ) with preserved blood flow (5.8 cm/s) (arrows) ( B ). Furthermore, dilatation of arcuate veins within the myometrium communicating to pelvic varicosities (arrows) ( C ) with enhanced blood flow in the power Doppler option (arrows) ( D ) was observed in this patient. Fig. 2 TVUS examination of a 34-year-old woman with typical PeVD symptoms: dilated right ovarian vein (diameter of 10 mm) (arrows) ( A ) with low blood flow (2.2 cm/s) observed in colour Doppler option (arrows) ( B,C ). Fig. 3 TVUS examination of a 32-year-old woman with typical PeVD symptoms: dilatation of arcuate veins within the myometrium communicating to pelvic varicosities (arrows) ( A ) with enhanced blood flow in power Doppler option (arrows) ( B ). Fig. 4 TVUS examination of a 26-year-old woman with typical PeVD symptoms: dilated left ovarian vein (diameter of 9 mm) (arrows) ( A ) with preserved blood flow (11.5 cm/s) (arrows) ( B ), observed also in colour Doppler option (arrows) ( C ). TVUS examination of a 37-year-old woman with typical PeVD symptoms: dilated left ovarian vein (diameter of 9 mm) (arrows) ( A ) with preserved blood flow (5.8 cm/s) (arrows) ( B ). Furthermore, dilatation of arcuate veins within the myometrium communicating to pelvic varicosities (arrows) ( C ) with enhanced blood flow in the power Doppler option (arrows) ( D ) was observed in this patient. TVUS examination of a 34-year-old woman with typical PeVD symptoms: dilated right ovarian vein (diameter of 10 mm) (arrows) ( A ) with low blood flow (2.2 cm/s) observed in colour Doppler option (arrows) ( B,C ). TVUS examination of a 32-year-old woman with typical PeVD symptoms: dilatation of arcuate veins within the myometrium communicating to pelvic varicosities (arrows) ( A ) with enhanced blood flow in power Doppler option (arrows) ( B ). TVUS examination of a 26-year-old woman with typical PeVD symptoms: dilated left ovarian vein (diameter of 9 mm) (arrows) ( A ) with preserved blood flow (11.5 cm/s) (arrows) ( B ), observed also in colour Doppler option (arrows) ( C ). Finally, patients with typical symptoms of PeVD lasting for at least 6 months and meeting at least one PeVD criterium in TVUS were referred to the Department of Interventional Radiology and Neuroradiology of the Medical University of Lublin to perform pelvic venography and subsequent pelvic vein embolization if required. Pelvic vein embolization was performed only in the case of patients in whom conservative treatment did not bring the desired effect. The venographic criteria for the diagnosis of PeVD included the presence of at least one of the following: dilatation of ovarian veins (> 5 mm), retrograde ovarian vein reflux, uterine venous enlargement, cross-filling of pelvic veins across the midline with filling of vulvovaginal or thigh varicosities and stasis of contrast material in pelvic venous plexus. Pelvic venography was performed by an interventional radiologist via percutaneous access in the local anaesthesia with the Seldinger method, which means, that the femoral or carotid vein was punctured by an 18G needle with a lumen inside. Through that lumen first guidewire, and then over the wire, the sheath was advanced. When the dilatation of the ovarian vein and its insufficiency were confirmed, the catheter was advanced selectively and distally. Venography was performed with the Valsalva manoeuvre. Then obliteration of the insufficient para-uterine plexus and veins using aethoxysclerol foam was performed. The ovarian vein was embolized with sandwich technique which means that foam and platinum spirals were alternately administered. Using an appropriately similar technique, other insufficient veins were embolized 24 (Figs.  5 , 6 ). The cost of the procedure is covered by the National Health Fund. Fig. 5 TVUS examination of a 52-year-old woman with typical PeVD symptoms: dilated left ovarian vein (diameter of 8 mm) with reflux (> 1 s) (arrows) ( A ). Venography of the left renal vein confirmed reflux of contrast medium through the incompetent ovarian vein into the uterine venous plexus (arrows) ( B ). Control venography after embolization of the plexuses and the incompetent ovarian vein revealed normal drainage from the left renal vein and reflux into the left ovarian vein (arrows) ( C ). Fig. 6 Left ovarian vein venography in a 32-year-old woman with typical PeVD symptoms during the Valsalva manoeuvre. Visible retrograde flow to the dilated parametrial, paravaginal and perineal varicose plexuses (arrows) ( A ). Left ovarian vein venography in a 50-year-old woman after hysterectomy due to chronic pelvic pain. Venous leaks through the pelvic outlets feeding the varicose veins of the left lower limb were visualized (arrows) ( B ). Left renal vein venography in a nulligravida 20-year-old woman with typical PeVD symptoms. A compressed renal vein with outflow through collateral vessels was revealed (arrows) ( C ). TVUS examination of a 52-year-old woman with typical PeVD symptoms: dilated left ovarian vein (diameter of 8 mm) with reflux (> 1 s) (arrows) ( A ). Venography of the left renal vein confirmed reflux of contrast medium through the incompetent ovarian vein into the uterine venous plexus (arrows) ( B ). Control venography after embolization of the plexuses and the incompetent ovarian vein revealed normal drainage from the left renal vein and reflux into the left ovarian vein (arrows) ( C ). Left ovarian vein venography in a 32-year-old woman with typical PeVD symptoms during the Valsalva manoeuvre. Visible retrograde flow to the dilated parametrial, paravaginal and perineal varicose plexuses (arrows) ( A ). Left ovarian vein venography in a 50-year-old woman after hysterectomy due to chronic pelvic pain. Venous leaks through the pelvic outlets feeding the varicose veins of the left lower limb were visualized (arrows) ( B ). Left renal vein venography in a nulligravida 20-year-old woman with typical PeVD symptoms. A compressed renal vein with outflow through collateral vessels was revealed (arrows) ( C ). The team of Interventional radiologists performed pelvic venography for every patient without knowledge of the TVUS results. For each of the patients included in the study, this was the first pelvic venography examination performed. The mean age of patients recruited in the study was 36.4 years ± 8,58 (range 16–77 years). Most of the patients (79.5%) were premenopausal, 22.6% of them had a history of using contraception, and 85,1% had a history of pregnancy in the past. Current symptoms were as follows: back pain (65.6% of the patients), hip (30.8%) and leg pain (70.3%), dyspareunia (71.8%), postcoital pain (75.6%), urinary urgency (35,4%), constipation (48.2%), flatulence (76.9%), lower limb oedema (43.1%), lower limb varicose veins (40%), haemorrhoids (36.9%) and vulvar varicose veins (27.7%). The severity of the pain assessed by participants was as follows: pain significantly influencing daily functioning (73.8%), pain influencing daily life at a mild level (21,5%) and 4,7% of patients reporting pain with no effect on the quality of their life. The research was approved by the Local Bioethics Committee of the Medical University of Lublin (KB-0024/156/11/2024). Written informed consent to participate in the study was obtained from every patient. All research methods used in the study were performed in accordance with the guidelines of the Local Bioethics Committee, the regulations of the Medical University of Lublin and the.

To conclude, primary gynaecological diagnostics based predominantly on TVUS appears to be crucial in identifying patients with PeVD. Using appropriate criteria, high efficiency in the first-line diagnostics of such patients could be obtained.

Gynaecological diagnostics consisting of medical history, physical examination and TVUS are characterized by high effectiveness in diagnosing pelvic pathologies including PeVD. In our study, the diagnostic effectiveness of TVUS for PeVD detection was 95.9%. TVUS is a cost-effective, non-invasive diagnostic method that can be performed in most medical offices. Moreover, this method may contribute to detecting other pathologies that may strengthen CPP symptoms, like uterine fibroids, endometriosis, adenomyosis or ovarian tumours. Furthermore, ultrasound examination does not require contrast agents as in the case of computed tomography or magnetic resonance imaging 12 . It remains a matter of debate which ultrasound parameter is the most appropriate to identify patients with PeVD. Dilatation of arcuate veins within the myometrium communicating to pelvic varicosities observed in TVUS was confirmed in pelvic venography in 96.4% of our patients. However, the evaluation of this parameter is controversial. The ultrasound evaluation in this case is subjective and the result may vary depending on the method of conducting the examination and the interpretation of the examiner. However, in our study, each sonographer examined patients according to the same specially prepared protocol, which undoubtedly increased the repeatability of the obtained results. Using a cut-off diameter of more than 8 mm for ovarian veins, venography confirmed the TVUS findings in all our studied patients. It remains a matter of debate whether ovarian vein dilatation should be used in the diagnosis of PeVD and, if so, what cut-off value should be used 25 . Results of our research show that a cut-off diameter of the left ovarian vein of 6.0 mm had a sensitivity of 73.08% and, a specificity of 80.0%. The cut-off diameter of the right ovarian vein of 5.5 mm had a sensitivity of 58.87% and a specificity of 100.0% in PeVD detection. The differences in the diameter of the right and left ovarian veins result from the anatomical differences in the course of the veins and the physiological anteversion and slight torsion of the uterus to the right. It appears that the use of such a cut-off diameter would result in a more accurate diagnosis of PeVD. Assuming a maximum blood velocity in the ovarian vein of less than 3 cm/s, venography confirmed the TVUS findings in 96.1% of our patients. Assuming a duration of reflux of more than 1 cm/s in the ovarian vein, venography confirmed the TVUS findings in 97.5% of our patients. This is a preliminary study regarding the effectiveness of diagnostic methods. It is planned to evaluate the effectiveness of treatment after 3, 6 and 12 months and correlate it with symptoms and diagnostics.

Chronic Pelvic Pain (CPP) is one of the most common condition encountered in the daily practice of gynaecologists. CPP refers to intermittent or constant pain located in the pelvis or lower abdomen of a woman that lasts for at least 6 months, whereas the occurrence of pain is not related purely and simply to the menstrual cycle, sexual intercourse or pregnancy 1 , 2 . Prevalence estimates for CPP vary from 6.4 to 25.4% depending on population and established criteria, resulting in a heavy social and economic burden 3 – 8 . The diagnosis of CPP is challenging. In many cases, a gynaecologist is not the first-line physician to diagnose such a patient. Quite often, they undergo in-depth diagnostics including neurological (anterior cutaneous nerve entrapment syndrome, nociplastic pain), urological (cystitis, bladder cancer), gastrointestinal (irritable bowel syndrome, inflammatory bowel disease, gastrointestinal cancer), musculoskeletal (myofascial pain syndrome, fibromyalgia, coccydynia) and mental health disorders. Despite thorough diagnostics, it turns out that the problem lies elsewhere 9 – 11 . Among the possible reasons of CPP one of the most challenging are Pelvic Venous Disorders (PeVD) 12 , 13 . PeVD are a group of diseases characterized by the coexistence of CPP and varicose veins localized in the pelvis and lower abdomen 12 , 14 , 15 . In addition to the typical manifestation of PeVD as CPP, there are also additional symptoms that may indicate this aetiology. PeVD may demonstrate itself as chronic, non-cyclic pelvic, abdominal, back, hip and leg pain that is worsened by prolonged standing, sitting or walking and decreases when lying down. Other symptoms include dyspareunia, postcoital pain, urinary urgency, vulvar swelling, persistent genital arousal disorder, vaginal discharge and bleeding 11 , 15 – 17 . Pelvic venography is considered the gold standard for diagnosing PeVD 5 . It allows for obtaining a detailed image of venous anatomy, reflux observation, and most importantly simultaneous intervention through pelvic vein embolization. However, it is an invasive method requiring the administration of contrast 18 , 19 . Noninvasive imaging techniques seem to be crucial for diagnosing PeVD. Transvaginal Ultrasonography (TVUS) in the clinical practice of a gynaecologist is the predominant diagnostic method modality in patients with symptoms of PeVD 12 . Our study aimed to assess the usefulness of TVUS in diagnosing PeVD and to determine ultrasound parameters that are useful in identifying such patients.