Pelvic congestion syndrome – ectasia of the vessels of the venous system of the pelvis, leading to impaired blood flow from the internal and external genitalia. It is manifested by a visible expansion of the perineal and vulvar veins, accompanied by local edema, a feeling of heaviness and bursting pains, bleeding. Pelvic pain, dysmenorrhea, dyspareunia, and other symptoms are characteristic. Pelvic congestion syndrome are diagnosed by gynecological examination and ultrasound, phlebography, CT, laparoscopy. Treatment of the syndrome can be conservative (venotonics, physical therapy) or surgical (sclerobliteration / embolization of gonadal veins, phlebectomy, etc.).
Pelvic congestion syndrome (PCS) is a disease of the pelvic veins associated with a violation of their architectonics and stagnation of venous blood in the pelvis. In the literature, pelvic congestion syndrome are also referred to by the terms “pelvic venous fullness syndrome”, “varicocele in women”, “chronic pelvic pain syndrome”. The prevalence of pelvic congestion syndrome increases in proportion to age: from 19.4% in girls under 17 to 80% in perimenopausal women. The most common pathology of pelvic veins is diagnosed in the reproductive period in patients in the age group of 25-45 years. In the vast majority of cases (80%), varicose transformation affects the ovarian veins and is extremely rare (1%) observed in the veins of the broad ligament of the uterus. According to modern medical approaches, the treatment of PCS should be carried out not so much from the standpoint of gynecology, but, above all, from the standpoint of phlebology.
The pathomorphological basis of pelvic congestion syndrome is considered to be connective tissue dysplasia, which occurs in 35% of practically healthy people. This condition is congenital and is characterized by a decrease in the content of certain types of collagen, which causes a decrease in the strength of connective tissue, including the component of the vessel wall. The extreme manifestation of such pathology may be the underdevelopment or absence of any morphological component of the vascular wall. Systemic connective tissue damage explains the frequent combination of PCS with varicose veins of the lower extremities and hemorrhoids. In addition to connective tissue dysplasia, a certain “weakening” effect on the tone of the venous system of the pelvis in women is exerted by sex hormones (mainly progesterone), PID, pelvic vein thrombosis.
Factors that increase the risk of pelvic congestion syndrome are heavy physical exertion; work associated with a forced prolonged stay in a standing or sitting position; pregnancy and childbirth, pelvic injuries, lack of orgasm in a woman. Of gynecological diseases, endometriosis, vaginal and uterine prolapse, tumors of the uterus and ovaries, retroflexia of the uterus, etc. have the most significant impact on the development of PCS. The triggering role of hormonal contraception and hormone replacement therapy is not excluded.
Pelvic congestion syndrome can manifest in two forms: varicose veins of the vulva and perineum and venous fullness syndrome. In more than half of the cases, both of these forms condition and support the flow of each other. Isolated vulvar and perineal varicose veins often occur as a result of blood reflux through the saphenofemoral junction with damage to the external genital vein and the inflow of the large saphenous vein. It occurs in 30% of pregnant women, after childbirth it persists in 2-10% of women. The main provoking factor of varicose veins of the perineum and vulva is the pressure of the growing uterus on the iliac and inferior vena cava. The pathomorphological prerequisite for pelvic congestion syndrome is blood reflux through the ovarian vein.
There are 3 degrees of severity of pelvic congestion syndrome , taking into account the diameter and localization of venous ectasia:
- Grade 1 – dilated vessels have a diameter of up to 0.5 cm and a convoluted course; the lesion may affect any of the venous plexuses of the pelvis;
- Grade 2 – dilated vessels have a diameter of 0.6-1 cm; the lesion may be total or affect the ovarian plexus, or parametral veins, or arcuate veins of the myometrium;
- Grade 3 – dilated vessels have a diameter of more than 1 cm with varicose veins of the total type or main type (parametral localization).
The basis of the clinical picture of vulvar and perineal varicose veins is the visible expansion of venous vessels in this area. Subjective complaints may include sensations of itching, discomfort, heaviness and bursting pains in the area of the external genitals. During examination, swelling of the labia may be detected. Spontaneous or post-traumatic bleeding may occur, more often provoked by sexual intercourse or childbirth. Due to the thinning of the venous wall and high pressure in the varicose veins, stopping such bleeding is associated with certain difficulties. Another complication of varicose veins of this localization may be acute thrombophlebitis of the perineal veins. In this case, intense pain, hyperemia and swelling of the skin of the perineum occur. Veins affected by varicose veins become dense and painful to the touch. Hyperthermic syndrome develops – an increase in body temperature to 37.5-38.0 ° C.
Another form of pelvic congestion syndrome – venous fullness syndrome – can give a polymorphic clinical picture, and therefore is often mistaken for inflammatory gynecological pathology, colitis, cystitis, lumbosacral radiculitis, etc. The most constant sign is pain in the lower abdomen, having different intensity, character and irradiation. More often, patients describe their feelings as aching pains that radiate to the lumbosacral region, groin or perineum. Almost half of women with pelvic congestion syndrome note an increase in pain syndrome in the second phase of the menstrual cycle. Often, pain is provoked by sexual intercourse, prolonged sitting or standing, physical exertion. For the syndrome of venous fullness of the pelvis, the presence of pronounced premenstrual syndrome, algodismenorrhea, dyspareunia, dysuric disorders is typical.
Diagnosis of pelvic congestion syndrome consists of a standard gynecological examination, ultrasound scanning of OMT and veins of the lower extremities, pelvic phlebography, CT of the pelvis, laparoscopy. A gynecologist and a phlebologist should participate in the examination of patients with suspected PCS.
Examination of the external genitals reveals dilated superficial veins in the vulva and perineum; vaginal examination determines cyanosis of the vaginal walls, tenderness during palpation of the abdomen. The sonography of the pelvic organs allows to confirm the PCS, while the combined ultrasound is the most informative. The study not only makes it possible to identify organic pathology, but also to detect conglomerates of varicose veins with altered blood flow, pathological blood reflux using the CDM mode. According to the Doppler ultrasound of the vessels, a decrease in the peak blood flow rate in the uterine, ovarian and internal iliac veins is determined. As part of the assessment of the phlebological status of the patient, it is advisable to conduct ultrasound angioscanning of the veins of the lower extremities.
In order to study the localization and prevalence of pelvic congestion syndrome, the condition of the valvular system and venous anastomoses, as well as the detection of blood clots, a peritoneal phlebography is performed. In case of venous fullness syndrome, selective ovariography may be indicated, involving the introduction of contrast directly into the ovarian veins. In isolated vulvar-perineal varicose veins, varicography is used – contrasting the veins of the perineum. Currently, X-ray contrast examination is being replaced by CT of the pelvic organs, which is not inferior to them in diagnostic significance. Within the framework of differential diagnosis, as well as with insufficient information content of the listed methods, diagnostic laparoscopy is resorted to.
During pregnancy, only symptomatic therapy of pelvic congestion syndrome is possible. It is recommended to wear compression tights, taking phlebotonics (diosmin, hesperidin) on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of varicose veins of the perineum can be performed. If there is a high risk of bleeding during independent childbirth due to varicose veins, the choice is made in favor of operative delivery.
Conservative tactics can be effective in case of grade 1-2 PCS. Course intake of venoactive and antiplatelet drugs, NSAIDs, physical therapy, ascending contrast shower, normalization of working conditions and physical activity, selection of compression knitwear and other measures can slow down the progression of varicose veins and significantly improve well-being. If dysfunctional uterine bleeding occurs, hemostatic therapy is prescribed. In some cases, the patient may need the help of a psychotherapist.
Uncupable pain syndrome, as well as varicose veins of the small pelvis of the 3rd degree serve as an indication for surgical treatment of pathology. Modern methods of minimally invasive surgery include sclerobliteration or embolization of ovarian veins, which are performed under angiographic control. During the intervention under local anesthesia, a sclerosant is injected into the lumen of the vessel or an embolization spiral is installed, resulting in obliteration / occlusion of the gonadal vein. A possible alternative is resection of ovarian veins by laparotomy or retroperitoneal access or their endoscopic clipping. If the cause of PCS is retroflexia of the uterus, plastic surgery of its ligamentous apparatus is performed.