Management of Patients when Superficial Venous Disease Arises from Pelvic Escape Points

Chronic pelvic pain (CPP) is a common condition in women that carries with it significant morbidity. It is commonly seen in patients presenting to obstetrics and gynecology outpatient clinic visits. CPP is a presenting symptom of various pathologies including pelvic varicocele, pelvic adhesions, spastic colon syndrome, uterine fibroids, endometriosis, and psychosomatic disorders. Pelvic congestion syndrome has more recently been termed “pelvic venous insufficiency (PVI)” due to the underlying retrograde flow through incompetent ovarian and pelvic veins that are thought to cause the symptoms of CPP. Pelvic varices can commonly present alongside vulvar, perineal, and lower extremity varices. There are some predictable “escape pathways” for these varices that may present for interventional treatment. This article introduces the reader to current terminology, clinical presentation, diagnosis, and treatment of patients with pelvic varices due to PVI.

pelvic varices - pelvic congestion syndrome - pelvic venous insufficiency - embolization - sclerotherapy - interventional radiologyEthical Approval IRB approval was not needed. Informed Consent Informed consent was not required for this study. Consent for Publication Consent for publication was not required for this study. No content of the study has been presented or published previously. Publication History Article published online: 03 June 2021 © 2021. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA -

- 1 Díaz-Mohedo E, Hita-Contreras F, Luque-Suárez A, Walker-Chao C, Zarza-Luciáñez D, Salinas-Casado J. Prevalence and risk factors of pelvic pain. Actas Urol Esp 2014; 38 (05) 298-303 - 2 Ayorinde AA, Bhattacharya S, Druce KL, Jones GT, Macfarlane GJ. Chronic pelvic pain in women of reproductive and post-reproductive age: a population-based study. Eur J Pain 2017; 21 (03) 445-455 - 3 Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996; 87 (03) 321-327 - 4 Stones RW, Price C. Health services for women with chronic pelvic pain. J R Soc Med 2002; 95 (11) 531-535 - 5 Moore J, Kennedy S. Causes of chronic pelvic pain. Best Pract Res Clin Obstet Gynaecol 2000; 14 (03) 389-402 - 6 Zondervan K, Barlow DH. Epidemiology of chronic pelvic pain. Best Pract Res Clin Obstet Gynaecol 2000; 14 (03) 403-414 - 7 Desimpelaere JH, Seynaeve PC, Hagers YM, Appel BJ, Mortelmans LL. Pelvic congestion syndrome: demonstration and diagnosis by helical CT. Abdom Imaging 1999; 24 (01) 100-102 - 8 Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent Radiol 2013; 30 (04) 372-380 - 9 Pelvic congestion syndrome: prevalence and quality of life. Accessed April 5, 2021 at: https://www.phlebolymphology.org/pelvic-congestion-syndrome-prevalence-quality-life/ - 10 Jurga-Karwacka A, Karwacki GM, Schoetzau A, Zech CJ, Heinzelmann-Schwarz V, Schwab FD. A forgotten disease: pelvic congestion syndrome as a cause of chronic lower abdominal pain. PLoS One 2019; 14 (04) e0213834 - 11 Royal College of Obstetricians and Gynaecologists (RCOG). The initial management of chronic pelvic pain. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2012 May. 16 p. (Green-top Guideline; no. 41) - 12 Phillips D, Deipolyi AR, Hesketh RL, Midia M, Oklu R. Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management. J Vasc Interv Radiol 2014; 25 (05) 725-733 - 13 Hobbs JT. Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract 2005; 59 (10) 1195-1203 - 14 Kölbel T, Lindh M, Åkesson M, Wassèlius J, Gottsäter A, Ivancev K. Chronic iliac vein occlusion: midterm results of endovascular recanalization. J Endovasc Ther 2009; 16 (04) 483-491 - 15 Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006; 6: 177 - 16 Yosef A, Ahmed AG, Al-Hussaini T, Abdellah MS, Cua G, Bedaiwy MA. Chronic pelvic pain: pathogenesis and validated assessment. Middle East Fertil Soc J 2016; 21: 205-221 - 17 Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984; 2 (8409): 946-949 - 18 Kuligowska E, Deeds III L, Lu III K. Pelvic pain: overlooked and underdiagnosed gynecologic conditions. Radiographics 2005; 25 (01) 3-20 - 19 Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. BJOG An Int J Obstet Gynaecol. 1988; 95 (02) 153-161 - 20 Giacchetto C, Cotroneo GB, Marincolo F, Cammisuli F, Caruso G, Catizone F. Ovarian varicocele: ultrasonic and phlebographic evaluation. J Clin Ultrasound 1990; 18 (07) 551-555 - 21 Rozenblit AM, Ricci ZJ, Tuvia J, Amis Jr ES. Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. AJR Am J Roentgenol 2001; 176 (01) 119-122 - 22 Greiner M, Gilling-Smith GL. Leg varices originating from the pelvis: diagnosis and treatment. Vascular 2007; 15 (02) 70-78 - 23 Villavicencio JL. Recurrent leg varices and intrapelvic and extrapelvic venous connections: it's anatomy, my dear Watson!. Vascular 2007; 15 (02) 61-62 - 24 Wheelock K. Pelvic congestion syndrome and its relationship to varices of the lower extremities: a literature review. J Diagnostic Med Sonogr 2009; 25: 250-254 - 25 Kim AS, Greyling LA, Davis LS. Vulvar varicosities: a review. Dermatol Surg 2017; 43: 351-356 - 26 Royle JP, Macafee CAJ, Beischer NA. An unusual presentation of varicose veins of the vulva. Aust N Z J Obstet Gynaecol 1971; 11 (02) 122-125 - 27 Gloviczki P, Comerota AJ, Dalsing MC. et al; Society for Vascular Surgery, American Venous Forum. 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 - 28 Park SJ, Lim JW, Ko YT. et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol 2004; 182 (03) 683-688 - 29 Awad AS, Taha MMM, Manaf MHA, Gad MMM, Mashhour SN. Role of multi-detector CT venography in evaluation of pelvic congestion syndrome. Egypt J Radiol Nucl Med 2020; 51 (01) 159 - 30 Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 2018; 97 (07) 776-786 - 31 Coakley FV, Varghese SL, Hricak H. CT and MRI of pelvic varices in women. J Comput Assist Tomogr 1999; 23 (03) 429-434 - 32 Bookwalter CA, VanBuren WM, Neisen MJ, Bjarnason H. Imaging appearance and nonsurgical management of pelvic venous congestion syndrome. Radiographics 2019; 39 (02) 596-608 - 33 Umeoka S, Koyama T, Togashi K, Kobayashi H, Akuta K. Vascular dilatation in the pelvis: identification with CT and MR imaging. Radiographics 2004; 24 (01) 193-208 - 34 Dohke M, Watanabe Y, Okumura A. et al. Comprehensive MR imaging of acute gynecologic diseases. Radiographics 2000; 20 (06) 1551-1566 - 35 Lebowitz JA, Rofsky NM, Krinsky GA, Weinreb JC. Gadolinium-enhanced body MR venography with subtraction technique. AJR Am J Roentgenol 1997; 169 (03) 755-758 - 36 Black CM, Thorpe K, Venrbux A. et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol 2010; 21 (06) 796-803 - 37 Kauppila A. Uterine phlebography with venous compression. A clinical and roentgenological study. Acta Obstet Gynecol Scand Suppl 1970; 3 (Suppl. 03) 1-66 - 38 Jung SC, Lee W, Chung JW. et al. Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings. Radiographics 2009; 29 (02) 525-536 - 39 Peh WC, Wong JW, Tso WK, Chien EP. Intraosseous venous drainage anomaly of the tibia treated with imaging-guided sclerotherapy. Br J Radiol 2000; 73 (865) 80-82 - 40 Díaz-Candamio MJ, Lee VS, Golimbu CN, Scholes JV, Rofsky NM. Intrafibular varix: MR diagnosis. J Comput Assist Tomogr 1999; 23 (02) 328-330 - 41 Boutin RD, Sartoris DJ, Rose SC. et al. Intraosseous venous drainage anomaly in patients with pretibial varices: imaging findings. Radiology 1997; 202 (03) 751-757 - 42 Chi C, Taylor A, Munjuluri N, Abdul-Kadir R. A diagnostic dilemma: round ligament varicosities in pregnancy. Acta Obstet Gynecol Scand 2005; 84 (11) 1126-1127 - 43 Pilkington SA, Rees M, Jones O, Green I. Ultrasound diagnosis of round ligament varicosities mimicking inguinal hernias in pregnancy. Ann R Coll Surg Engl 2004; 86 (05) 400-401 - 44 Nguyen QH, Gruenewald SM. Doppler sonography in the diagnosis of round ligament varicosities during pregnancy. J Clin Ultrasound 2008; 36 (03) 177-179 - 45 Huang A, Tweedie JH. Reducible inguinal swelling presenting during pregnancy-not always a hernia. J Obstet Gynaecol 1998; 18 (03) 284 - 46 Cheng D, Lam H, Lam C. Round ligament varices in pregnancy mimicking inguinal hernia: an ultrasound diagnosis. Ultrasound Obstet Gynecol 1997; 9 (03) 198-199 - 47 Peirce RM, Funaki B. Direct MR venography of persistent sciatic vein in a patient with Klippel-Trenaunay-Weber syndrome. AJR Am J Roentgenol 2002; 178 (02) 513-514 - 48 Noel AA, Gloviczki P, Cherry Jr KJ, Rooke TW, Stanson AW, Driscoll DJ. Surgical treatment of venous malformations in Klippel-Trénaunay syndrome. J Vasc Surg 2000; 32 (05) 840-847 - 49 Cherry KJ, Gloviczki P, Stanson AW. Persistent sciatic vein: diagnosis and treatment of a rare condition. J Vasc Surg 1996; 23 (03) 490-497 - 50 Trigaux J-PF, Vanbeers BE, Delchambre FE, de Fays FM, Schoevaerdts J-CM. Sciatic venous drainage demonstrated by varicography in patients with a patent deep venous system. Cardiovasc Intervent Radiol 1989; 12 (02) 103-106 - 51 Lee A, Driscoll D, Gloviczki P, Clay R, Shaughnessy W, Stans A. Evaluation and management of pain in patients with Klippel-Trenaunay syndrome: a review. Pediatrics 2005; 115 (03) 744-749 - 52 Jacob AG, Driscoll DJ, Shaughnessy WJ, Stanson AW, Clay RP, Gloviczki P. Klippel-Trénaunay syndrome: spectrum and management. Mayo Clin Proc 1998; 73 (01) 28-36 - 53 Bastarrika G, Redondo P, Sierra A. et al. New techniques for the evaluation and therapeutic planning of patients with Klippel-Trénaunay syndrome. J Am Acad Dermatol 2007; 56 (02) 242-249 - 54 Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: evaluation with CT. Radiographics 1995; 15 (03) 609-622 - 55 Henseler KP, Pozniak MA, Lee Jr FT, Winter III TC. Three-dimensional CT angiography of spontaneous portosystemic shunts. Radiographics 2001; 21 (03) 691-704 - 56 Edwards RD, Robertson IR, MacLean AB, Hemingway AP. Case report: pelvic pain syndrome--successful treatment of a case by ovarian vein embolization. Clin Radiol 1993; 47 (06) 429-431 - 57 Maleux G, Stockx L, Wilms G, Marchal G. Ovarian vein embolization for the treatment of pelvic congestion syndrome: long-term technical and clinical results. J Vasc Interv Radiol 2000; 11 (07) 859-864 - 58 Katz MD, Sugay SB, Walker DK, Palmer SL, Marx MV. Beyond hemostasis: spectrum of gynecologic and obstetric indications for transcatheter embolization. Radiographics 2012; 32 (06) 1713-1731 - 59 De Gregorio MA, Guirola JA, Alvarez-Arranz E, Sánchez-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) 1560-1569 - 60 Koo S, Fan C-M. Pelvic congestion syndrome and pelvic varicosities. Tech Vasc Interv Radiol 2014; 17 (02) 90-95 - 61 Rastogi N, Kabutey N-K, Kim D. Unintended coil migration into the right ventricle during the right ovarian vein coil embolization. Vasc Endovascular Surg 2011; 45 (07) 660-664 - 62 Creton D, Hennequin L, Kohler F, Allaert FA. Embolisation of symptomatic pelvic veins in women presenting with non-saphenous varicose veins of pelvic origin - three-year follow-up. Eur J Vasc Endovasc Surg 2007; 34 (01) 112-117 - 63 Mahorner HR, Ochsner A. The modern treatment of varicose veins as indicated by the comparative Tourniquet Test. Ann Surg 1938; 107 (06) 927-951