Interventional Radiology Treatments to Address Chronic Pelvic Pain in Females

Background Chronic pelvic pain (CPP) affects about one in four women globally and has a variety of etiologies, including gynecologic causes. Interventional radiology (IR) offers minimally invasive treatment options for several of these etiologies. Purpose This review provides an overview of IR interventions for treating gynecologic causes of CPP, including fibroids, adenomyosis, pelvic venous disease (PeVD), endometriosis, and peritoneal inclusion cysts (PICs).

A narrative review was conducted on IR techniques for managing gynecologic causes of CPP, with emphasis on procedural applications, clinical presentation, and diagnostic approaches.

Uterine artery embolization (UAE) has shown effectiveness in treating fibroids and is increasingly applied for adenomyosis, while gonadal vein embolization is effective for managing PeVD. Emerging IR techniques show promise for treating endometriosis and PICs. This review discusses patient presentation, diagnostic evaluation, and procedural details unique to each condition.

As IR options for CPP expand, a comprehensive understanding of the clinical and procedural nuances can broaden the scope of effective treatment options. Similar content being viewed by others

Lamvu G, Carrillo J, Ouyang C, Rapkin A. chronic pelvic pain in women: a review. JAMA. 2021;325(23):2381–91. https://doi.org/10.1001/jama.2021.2631. Tanaka ME, Keefe N, Caridi T, Kohi M, Salazar G. Interventional radiology in obstetrics and gynecology: updates in women’s health. Radiographics. 2023;43(3):e220039. https://doi.org/10.1148/rg.220039. Lamvu G, Williams R, Zolnoun D, et al. Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: one year after evaluation in a pelvic pain specialty clinic. Am J Obstet Gynecol. 2006;195(2):591–8. https://doi.org/10.1016/j.ajog.2006.03.081. Chronic Pelvic Pain. ACOG practice bulletin, number 218. Obstet Gynecol. 2020;135(3):e98–109. https://doi.org/10.1097/AOG.0000000000003716. Vercellini P. Chronic pelvic. Pain. 2023. https://doi.org/10.1002/9781444391855. Hutton D, Mustafa A, Patil S, et al. The burden of chronic pelvic pain (CPP): closts and quality of life of women and men with CPP treated in outpatient referral centers. PLoS ONE. 2023;18(2):e0269828. https://doi.org/10.1371/journal.pone.0269828. Marsh EE, Al-Hendy A, Kappus D, Galitsky A, Stewart EA, Kerolous M. Burden, prevalence, and treatment of uterine fibroids: a survey of US women. J Womens Health (Larchmt). 2018;27(11):1359–67. https://doi.org/10.1089/jwh.2018.7076. Chung YJ, Rha SE, Kim MR, Shin YR. Correlation between MRI features of adenomyosis and clinical presentation. Diagnostics (Basel). 2023. https://doi.org/10.3390/diagnostics13172749. Meissner MH, Khilnani NM, Labropoulos N, et al. The symptoms-varices-pathophysiology classification of pelvic venous disorders: a report of the American vein and lymphatic society international working group on pelvic venous disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568–84. https://doi.org/10.1016/j.jvsv.2020.12.084. Khilnani NM, Winokur RS, Scherer KL, Meissner MH. Clinical presentation and evaluation of pelvic venous disorders in women. Tech Vasc Interv Radiol. 2021;24(1):100730. https://doi.org/10.1016/j.tvir.2021.100730. Khilnani NM, Meissner MH, Learman LA, et al. Research priorities in pelvic venous disorders in women: recommendations from a multidisciplinary research consensus panel. J Vasc Interv Radiol. 2019;30(6):781–9. https://doi.org/10.1016/j.jvir.2018.10.008. Falcone T, Flyckt R. Clinical management of endometriosis. Obstet Gynecol. 2018;131(3):557–71. https://doi.org/10.1097/AOG.0000000000002469. Balasch J, Creus M, Fabregues F, et al. Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study. Hum Reprod. 1996;11(2):387–91. https://doi.org/10.1093/humrep/11.2.387. Carter JE. Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain. J Am Assoc Gynecol Laparosc. 1994;2(1):43–7. https://doi.org/10.1016/s1074-3804(05)80830-8. Vallerie AM, Lerner JP, Wright JD, Baxi LV. Peritoneal inclusion cysts: a review. Obstet Gynecol Surv. 2009;64(5):321–34. https://doi.org/10.1097/OGX.0b013e31819f93d4. Rapisarda AMC, Cianci A, Caruso S, et al. Benign multicystic mesothelioma and peritoneal inclusion cysts: are they the same clinical and histopathological entities? A systematic review to find an evidence-based management. Arch Gynecol Obstet. 2018;297(6):1353–75. https://doi.org/10.1007/s00404-018-4728-2. Chand MT, Edens J, Lin T, Anderson I, Berri R. Benign multicystic peritoneal mesothelioma: literature review and update. Autops Case Rep. 2020;10(3):e2020159. https://doi.org/10.4322/acr.2020.159. Ross MJ, Welch WR, Scully RE. Multilocular peritoneal inclusion cysts (so-called cystic mesotheliomas). Cancer. 1989;64(6):1336–46. https://doi.org/10.1002/1097-0142(19890915)64:6%3c1336::aid-cncr2820640628%3e3.0.co;2-x. Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. Int J Gynaecol Obstet. 2020;149(1):3–9. https://doi.org/10.1002/ijgo.13102. Sarin SN, Baarson C, Hanif S, Awan Y, Venbrux AC. Uterine artery embolization. In: Ignacio E, Venbrux AC, editors. Women’s Health in Interventional Radiology. New York, NY: Springer New York; 2012. p. 3–36. https://doi.org/10.1007/978-1-4419-5876-1_1. Cao CD, Teefey P. Collaborative efforts between interventional radiology and obstetrics/gynecology. Tech Vasc Interv Radiol. 2021;24(1): 100729. https://doi.org/10.1016/j.tvir.2021.100729. Nakhaei M, Faintuch S, Brook OR. Impact of evaluation in interventional radiology clinic prior to uterine artery embolization: changes in management. Abdom Radiol (NY). 2020;45(3):878–84. https://doi.org/10.1007/s00261-019-02388-3. Bridger C, Prabhala T, Dawson R, et al. neuromodulation for chronic pelvic pain: a single-institution experience with a collaborative team. Neurosurgery. 2021;88(4):819–27. https://doi.org/10.1093/neuros/nyaa537. Scultetus AH, Villavicencio JL, Gillespie DL, Kao TC, Rich NM. The pelvic venous syndromes: analysis of our experience with 57 patients. J Vasc Surg. 2002;36(5):881–8. https://doi.org/10.1067/mva.2002.129114. Sulakvelidze L, Tran M, Kennedy R, Lakhanpal S, Pappas PJ. Presentation patterns in women with pelvic venous disorders differ based on age of presentation. Phlebology. 2021;36(2):135–44. https://doi.org/10.1177/0268355520954688. Gloviczki P, Comerota AJ, Dalsing MC, et al. 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. 2011;53(5 Suppl):2S-48S. https://doi.org/10.1016/j.jvs.2011.01.079. Rundqvist E, Sandholm LE, Larsson G. Treatment of pelvic varicosities causing lower abdominal pain with extraperitoneal resection of the left ovarian vein. Ann Chir Gynaecol. 1984;73(6):339–41. Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med. 2003;201(3):131–8. https://doi.org/10.1620/tjem.201.131. Bookwalter CA, VanBuren WM, Neisen MJ, Bjarnason H. Imaging appearance and nonsurgical management of pelvic venous congestion syndrome. Radiographics. 2019;39(2):596–608. https://doi.org/10.1148/rg.2019180159. Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 1984;2(8409):946–9. https://doi.org/10.1016/s0140-6736(84)91165-6. Hiromura T, Nishioka T, Nishioka S, Ikeda H, Tomita K. Reflux in the left ovarian vein: analysis of MDCT findings in asymptomatic women. AJR Am J Roentgenol. 2004;183(5):1411–5. https://doi.org/10.2214/ajr.183.5.1831411. Basile A, Failla G, Gozzo C. Pelvic congestion syndrome. Semin Ultrasound CT MR. 2021;42(1):3–12. https://doi.org/10.1053/j.sult.2020.07.001. Rahmioglu N, Nyholt DR, Morris AP, Missmer SA, Montgomery GW, Zondervan KT. Genetic variants underlying risk of endometriosis: insights from meta-analysis of eight genome-wide association and replication datasets. Hum Reprod Update. 2014;20(5):702–16. https://doi.org/10.1093/humupd/dmu015. Wang PH, Yang ST, Chang WH, Liu CH, Lee FK, Lee WL. Endometriosis: Part I basic concept. Taiwan J Obstet Gynecol. 2022;61(6):927–34. https://doi.org/10.1016/j.tjog.2022.08.002. Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;2(2):CD009591. https://doi.org/10.1002/14651858.CD009591.pub2. Guerriero S, Condous G, van den Bosch T, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the international deep endometriosis analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016;48(3):318–32. https://doi.org/10.1002/uog.15955. Bazot M, Thomassin I, Hourani R, Cortez A, Darai E. Diagnostic accuracy of transvaginal sonography for deep pelvic endometriosis. Ultrasound Obstet Gynecol. 2004;24(2):180–5. https://doi.org/10.1002/uog.1108. Bazot M, Darai E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril. 2017;108(6):886–94. https://doi.org/10.1016/j.fertnstert.2017.10.026. Kiesel L, Sourouni M. Diagnosis of endometriosis in the 21st century. Climacteric. 2019;22(3):296–302. https://doi.org/10.1080/13697137.2019.1578743. Nisolle M, Donnez J. Reprint of: peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril. 2019;112(4 Suppl1):e125–36. https://doi.org/10.1016/j.fertnstert.2019.08.081. Doiron T, Stambough K, Hollenbach L, Wong K. Recurrent peritoneal inclusion cysts in a patient with extensive surgical history successfully treated with sclerotherapy. J Pediatr Adolesc Gynecol. 2022;35(2):216. https://doi.org/10.1016/j.jpag.2022.01.061. Kim JS, Lee HJ, Woo SK, Lee TS. Peritoneal inclusion cysts and their relationship to the ovaries: evaluation with sonography. Radiology. 1997;204(2):481–4. https://doi.org/10.1148/radiology.204.2.9240539. McFadden DE, Clement PB. Peritoneal inclusion cysts with mural mesothelial proliferation. A clinicopathological analysis of six cases. Am J Surg Pathol. 1986;10(12):844–54. https://doi.org/10.1097/00000478-198612000-00003. Sohaey R, Gardner TL, Woodward PJ, Peterson CM. Sonographic diagnosis of peritoneal inclusion cysts. J Ultrasound Med. 1995;14(12):913–7. https://doi.org/10.7863/jum.1995.14.12.913. Jain KA. Imaging of peritoneal inclusion cysts. AJR Am J Roentgenol. 2000;174(6):1559–63. https://doi.org/10.2214/ajr.174.6.1741559. Expert Panel on Women’s I, Atri M, Alabousi A, et al. ACR appropriateness criteria((R)) clinically suspected adnexal mass no acute symptoms. J Am Coll Radiol. 2019;16(5):77–93. https://doi.org/10.1016/j.jacr.2019.02.011. Romero JA, Kim EE, Kudelka AP, Edwards CL, Kavanagh JJ. MRI of recurrent cystic mesothelioma: differential diagnosis of cystic pelvic masses. Gynecol Oncol. 1994;54(3):377–80. https://doi.org/10.1006/gyno.1994.1227. O’Neil JD, Ros PR, Storm BL, Buck JL, Wilkinson EJ. Cystic mesothelioma of the peritoneum. Radiology. 1989;170(2):333–7. https://doi.org/10.1148/radiology.170.2.2643136. Kurachi H, Murakami T, Nakamura H, et al. Imaging of peritoneal pseudocysts: value of MR imaging compared with sonography and CT. AJR Am J Roentgenol. 1993;161(3):589–91. https://doi.org/10.2214/ajr.161.3.8352112. Tamai K, Koyama T, Saga T, et al. MR features of physiologic and benign conditions of the ovary. Eur Radiol. 2006;16(12):2700–11. https://doi.org/10.1007/s00330-006-0302-6. Spies JB. Current evidence on uterine embolization for fibroids. Semin Intervent Radiol. 2013;30(4):340–6. https://doi.org/10.1055/s-0033-1359727. Cappelli A, Mosconi C, Cocozza MA, et al. Uterine artery embolization for the treatment of symptomatic uterine fibroids of different sizes: a single center experience. J Pers Med. 2023. https://doi.org/10.3390/jpm13060906. Moss JG, Cooper KG, Khaund A, et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG. 2011;118(8):936–44. https://doi.org/10.1111/j.1471-0528.2011.02952.x. de Bruijn AM, Ankum WM, Reekers JA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol. 2016. https://doi.org/10.1016/j.ajog.2016.06.051. Caridi TM. Uterine artery embolization for adenomyosis. Tech Vasc Interv Radiol. 2021;24(1): 100726. https://doi.org/10.1016/j.tvir.2021.100726. Popovic M, Puchner S, Berzaczy D, Lammer J, Bucek RA. Uterine artery embolization for the treatment of adenomyosis: a review. J Vasc Interv Radiol. 2011;22(7):901–9. https://doi.org/10.1016/j.jvir.2011.03.013. de Bruijn AM, Smink M, Lohle PNM, et al. Uterine artery embolization for the treatment of adenomyosis: a systematic review and meta-analysis. J Vasc Interv Radiol. 2017;28(12):1629–42. https://doi.org/10.1016/j.jvir.2017.07.034. Momah-Ukeh I, Ertreo M. (2021) Essential interventional radiology review, a question and answer guide Yuan K, Zhang JL, Yan JY, et al. Uterine artery embolization with small-sized particles for the treatment of symptomatic adenomyosis: a 42-month clinical follow-up. Int J Gen Med. 2021;14:3575–81. https://doi.org/10.2147/IJGM.S312618. Sutanto SA, Tan M, Onida S, Davies AH. A systematic review on isolated coil embolization for pelvic venous reflux. J Vasc Surg Venous Lymphat Disord. 2022;10(1):224–32. https://doi.org/10.1016/j.jvsv.2021.07.006. Kashef E, Evans E, Patel N, Agrawal D, Hemingway AP. Pelvic venous congestion syndrome: female venous congestive syndromes and endovascular treatment options. CVIR Endovasc. 2023;6(1):25. https://doi.org/10.1186/s42155-023-00365-y. Scherer KL, Winokur RS. Techniques for embolization of the ovarian vein and pelvic reservoir. Tech Vasc Interv Radiol. 2023;26(2): 100899. https://doi.org/10.1016/j.tvir.2023.100899. Marcelin C, Le Bras Y, Molina Andreo I, Jambon E, Grenier N. Diagnosis and management of pelvic venous disorders in females. Diagnostics (Basel). 2022. https://doi.org/10.3390/diagnostics12102337. Laborda A, Medrano J, de Blas I, Urtiaga I, Carnevale FC, de Gregorio MA. Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Int Radiol. 2013;36(4):1006–14. https://doi.org/10.1007/s00270-013-0586-2. Nasser F, Cavalcante RN, Affonso BB, Messina ML, Carnevale FC, de Gregorio MA. Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. Int J Gynaecol Obstet. 2014;125(1):65–8. https://doi.org/10.1016/j.ijgo.2013.10.008. De Gregorio MA, Guirola JA, Alvarez-Arranz E, Sanchez-Ballestin M, Urbano J, Sierre S. Pelvic venous disorders in women due to pelvic varices: treatment by embolization: experience in 520 patients. J Vasc Interv Radiol. 2020;31(10):1560–9. https://doi.org/10.1016/j.jvir.2020.06.017. Avgerinos ED, Saadeddin Z, Humar R, et al. Outcomes of left renal vein stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2019;7(6):853–9. https://doi.org/10.1016/j.jvsv.2019.06.016. Liu Z, Gao N, Shen L, et al. Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients. Ann Vasc Surg. 2014;28(3):695–704. https://doi.org/10.1016/j.avsg.2013.05.019. Murali N, Gupta R, Desai KR. The role of iliac vein stent placement in pelvic venous disorder management. J Vasc Surg Venous Lymphat Disord. 2023. https://doi.org/10.1016/j.jvsv.2023.101696. Razavi MK, Jaff MR, Miller LE. Safety and effectiveness of stent placement for iliofemoral venous outflow obstruction: systematic review and meta-analysis. Circ Cardiovasc Interv. 2015;8(10): e002772. https://doi.org/10.1161/CIRCINTERVENTIONS.115.002772. Daugherty SF, Gillespie DL. Venous angioplasty and stenting improve pelvic congestion syndrome caused by venous outflow obstruction. J Vasc Surg Venous Lymphat Disord. 2015;3(3):283–9. https://doi.org/10.1016/j.jvsv.2015.01.003. Gavrilov SG, Vasilyev AV, Krasavin GV, Moskalenko YP, Mishakina NY. Endovascular interventions in the treatment of pelvic congestion syndrome caused by May-Thurner syndrome. J Vasc Surg Venous Lymphat Disord. 2020;8(6):1049–57. https://doi.org/10.1016/j.jvsv.2020.02.012. Ecker AM, Donnellan NM, Shepherd JP, Lee TT. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol. 2014. https://doi.org/10.1016/j.ajog.2014.04.011. Barat M, Dohan A, Kohi M, et al. Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: a review of current evidences. Diagn Interv Imaging. 2023. https://doi.org/10.1016/j.diii.2023.11.005. Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. Abdominal wall endometriomas. Am J Surg. 2003;185(6):596–8. https://doi.org/10.1016/s0002-9610(03)00072-2. Mistrangelo M, Gilbo N, Cassoni P, et al. Surgical scar endometriosis. Surg Today. 2014;44(4):767–72. https://doi.org/10.1007/s00595-012-0459-3. Razakamanantsoa L, Bodard S, Najdawi M, et al. Surgical and percutaneous image-guided therapies of abdominal wall endometriosis: a systematic review of current evidence. J Minim Invasive Gynecol Published online. 2024. https://doi.org/10.1016/j.jmig.2024.06.007. Najdawi M, Razakamanantsoa L, Mousseaux C, et al. Resolution of pain after percutaneous image-guided cryoablation of extraperitoneal endometriosis. J Vasc Interv Radiol. 2023;34(7):1192–8. https://doi.org/10.1016/j.jvir.2023.03.025. Smith KA, Welch BT, Kurup AN, et al. Feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis. Abdom Radiol (NY). 2022;47(8):2669–73. https://doi.org/10.1007/s00261-021-03344-w. Jouffrieau C, Cazzato RL, Gabriele V, et al. Percutaneous imaging-guided cryoablation of endometriosis scars of the anterior abdominal wall. J Minim Invasive Gynecol. 2023;30(11):890–6. https://doi.org/10.1016/j.jmig.2023.06.018. Liu Y, Wen W, Qian L, Xu R. Safety and efficacy of microwave ablation for abdominal wall endometriosis: a retrospective study. Front Surg. 2023;10:1100381. https://doi.org/10.3389/fsurg.2023.1100381. Baraki D, Richards EG, Falcone T. Treatment of endometriomas: Surgical approaches and the impact on ovarian reserve, recurrence, and spontaneous pregnancy. Best Pract Res Clin Obstet Gynaecol. 2024;92: 102449. https://doi.org/10.1016/j.bpobgyn.2023.102449. Azizova A, Ciftci TT, Gultekin M, et al. ethanol sclerotherapy in the management of ovarian endometrioma: technical considerations for catheter- and needle-directed sclerotherapy. Cardiovasc Intervent Radiol. 2024;47(7):891–900. https://doi.org/10.1007/s00270-024-03694-0. Lipitz S, Seidman DS, Schiff E, Achiron R, Menczer J. Treatment of pelvic peritoneal cysts by drainage and ethanol instillation. Obstet Gynecol. 1995;86(2):297–9. https://doi.org/10.1016/0029-7844(95)00157-m. Koninckx PR, Renaer M, Brosens IA. Origin of peritoneal fluid in women: an ovarian exudation product. Br J Obstet Gynaecol. 1980;87(3):177–83. https://doi.org/10.1111/j.1471-0528.1980.tb04514.x. Hoffer FA, Kozakewich H, Colodny A, Goldstein DP. Peritoneal inclusion cysts: ovarian fluid in peritoneal adhesions. Radiology. 1988;169(1):189–91. https://doi.org/10.1148/radiology.169.1.3047785. Cheng D, Amin P, Ha TV. Percutaneous sclerotherapy of cystic lesions. Semin Intervent Radiol. 2012;29(4):295–300. https://doi.org/10.1055/s-0032-1330063. Jeong JY, Kim SH. Sclerotherapy of peritoneal inclusion cysts: preliminary results in seven patients. Korean J Radiol Jul-Sep. 2001;2(3):164–70. https://doi.org/10.3348/kjr.2001.2.3.164. Lim HK, Cho JY, Kim SH. Sclerotherapy of peritoneal inclusion cysts: a long-term evaluation study. Abdom Imaging. 2010;35(4):431–6. https://doi.org/10.1007/s00261-009-9538-3. Funding This study was not supported by any funding. Author information Authors and Affiliations Corresponding author Ethics declarations Conflict of interest Gloria Salazar, MD has received speaker honorarium from Medtronic, Boston Scientific, Cook, Becton and Dickinson, Philips. Yuko McColgan is the Founder of Yuko Family Medicine- Yuko McColgan MD, LLC. Victoria Risner and Estefania Gonzales declare that they have no conflict of interest. Ethical Approval This article does not contain any studies with human participants or animals performed by any of the authors. Consent for Publication For this type of study consent for publication is not required. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Risner, V., Gonzales, E., McColgan, Y. et al. Interventional Radiology Treatments to Address Chronic Pelvic Pain in Females. Cardiovasc Intervent Radiol 48, 950–962 (2025). https://doi.org/10.1007/s00270-024-03823-9 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00270-024-03823-9