Chronic pelvic pain is a common condition and reports indicate that more than 30 percent of women complain about pain in the lower abdomen occasionally throughout their lifetime. Occasionally, it is also known as pelvic congestion syndrome (PCS).
What is pelvic congestion syndrome?
It is believed that this condition is associated with varicose veins in the pelvis (lower abdomen and groin). The varicose veins develop during pregnancy and continue to progress in size. The syndrome is associated with constant dull pelvic pain, pressure and heaviness. No one really knows why the varicose veins develop nor how to best treat it. In fact, there are some women in whom no identifiable cause is identified.
How can varicose veins develop?
In normally functioning veins, blood flows in only one direction, and is prevented from flowing backwards. When the valves are defective or injured, blood starts to flow backwards and engorge the veins in the pelvis. With the pooling of the blood in the veins, the veins get bigger in size and the walls are stretched. It is believed that these varicosities are located near nerves, which are stimulated and cause pain.
Why do varicose veins develop in pelvic congestion syndrome?
The exact cause of pelvic congestion syndrome is unknown. The possible causes may be:
- Physiological: In pregnancy there is a significant increase in fluid and weight gain is common. It is believed that this excess fluid and weight gain disrupts the vein and causes them to engorge with blood. Over time, the veins become distended and the condition progresses because the valves have been destroyed.
- Estrogen: It is known that estrogen can weaken the vein walls and during pregnancy the increase in estrogens may play a role in the development of varicose veins, which are so common. Perhaps that is why men do not develop this syndrome.
- Anatomic: Others believe that there may be some anatomical changes in the anatomy of the veins and other structures in the pelvis that may make them more susceptible to formation of varicose veins. The onset of pregnancy may make the veins more susceptible to damage and more prone to develop the varicosities.
How is pelvic congestion syndrome related to varicose veins in the legs?
Pelvic venous congestion syndrome is very similar to the condition of varicose veins in the legs. In both cases, the valves in the veins that help blood flow toward the heart are either defective or damaged. The function of the valves is to prevent backflow of blood. When the valves are destroyed, pooling of the blood occurs in the veins. The veins which are engorged with blood get bigger and stretch the vein wall. In pelvic congestion syndrome, the enlarged veins occur near the uterus, fallopian tubes, vulva and even the vagina. The condition is generally associated with weight gain, like that seen in pregnancy.
How many women get pelvic congestion syndrome?
The exact number of women who have pelvic congestion syndrome is unknown but it is estimated that more than 30 percent of women will experience chronic pelvic pain at some point in their lifetime. The term chronic pelvic pain is defined as non cyclical pain which lasts more than six months in duration. However, not all women who develop the syndrome will have symptoms.
Which women are more prone to developing pelvic congestion syndrome?
Pelvic congestion syndrome is generally seen in women:
- Between the ages of 20-45
- With multiple pregnancies
What is the most common complaint of pelvic congestion syndrome?
Pain of varying severity is the most common complaint. The pain is typically dull and not cyclical. The pain is usually worse:
- Just before the onset of the menstrual cycle
- At the end of the day
- After prolonged standing
- During or just after intercourse
- During later stages of pregnancy
What are other symptoms of pelvic congestion syndrome?
There are numerous other non specific symptoms, which are variable in intensity. In general, the symptoms are more common at the end of the day or after prolonged periods of standing or even after sexual intercourse. In some cases, the pain may be severe and affect personal and social relationship. Many women are forever seeking help for this enigmatic condition.
Symptoms of pelvic congestion syndrome may include:
- Swollen vulva/vagina
- Varicose veins (located on or around vulva, buttocks, legs)
- Abnormal menstrual bleeding
- Tenderness to touch in lower abdomen
- Pain during intercourse
- Painful menstrual periods
- Vaginal discharge
- General lethargy
- Feelings of depression
What other conditions can mimic pelvic venous congestion syndrome?
In most cases, the diagnosis of pelvic congestion syndrome is not obvious and the diagnosis can only be made after ruling out some other disorders. Other disorders that may have the same symptoms as PCS include:
- Uterine prolapse (the uterus drops lower in the pelvis as a result of weak muscles)
How is the diagnosis of PCS made?
PCS is a difficult diagnosis to make. All other conditions must be ruled out first. The specific diagnosis is made using several tests which include:
- Ultrasound: This is the first test of choice. It can assess the uterus and other organs in the pelvis. Technical advances in ultrasound can also help visualize the blood flow and asses the presence of varicosities in the pelvis. The procedure is painless and takes about 30 minutes. It is usually the first test of choice, cheap and effective.
- Venogram: This test was widely used in the past to make a diagnosis of PCS, but today has been replaced by CT scan. The test involves injecting of a special dye into one of the veins in the groin and obtaining X rays. The procedure takes about 30-45 minutes and is done as an outpatient procedure. The procedure is painless and done in a radiology suite. There is some radiation exposure and the risk of allergy to the dye is ever present.
- CT Scan: CT scan is frequently used in the diagnosis of PCS. It can look at the entire anatomy of the lower pelvis and identify varicosity of the pelvic veins. It is associated with radiation exposure and not a recommended test in pregnant females.
- MRI: MRI is a very useful test in the diagnosis of pelvic congestion syndrome. It does not use radiation or contrast dye and is a painless test. The images are excellent and it is the preferred test of choice for many radiologists. The test takes about 15 minutes and is an outpatient procedure.
Why is treatment of pelvic congestion syndrome difficult?
Because of the variability in the symptoms, the diagnosis of PCS is difficult. Despite making a diagnosis of varicosities in the pelvis, the treatment is not always successful and some individuals are not satisfied. The degree of discomfort and pain is so variable that a standard treatment protocol is not available. Before any treatment is undertaken, it is essential that other medical conditions have been ruled out.
What treatments are available for PCS?
There are a number of treatment options for PCS and these include both non surgical and surgical approaches. Today, we also have radiological techniques that are preferred to surgery.
What drugs can be used to treat PCS?
In the past, drugs (ergotamine) that narrowed the veins were tried out. In addition, hormones were also prescribed for pelvic congestion syndrome. Neither drugs nor hormones were successful, and today drug therapy is not used in the treatment of PCS. However, the pain may require prescription pain medications.
Another class of drugs that has shown some benefit is the use of antidepressants. These drugs are not only excellent pain relievers but also treat the depression and anxiety caused by PCS.
What is the role of alternative medicine in the treatment of PCS?
Many women are not satisfied with conventional medical therapy because of the high failure rate. Alternative health care approaches to the treatment of PCS have included:
- Physical therapy
- Transcutaneous electrical nerve stimulation
- Behavior and psychological counseling
- Trigger point injections
- Epidural and spinal nerve blocks
What is the role of surgery in treatment of pelvic congestion syndrome?
Today, surgery is not the first choice therapy for PCS. The surgery is always undertaken after all methods of treatment have failed. In addition, the individual must have symptoms which are still ongoing. The surgery may be done using a minimally invasive approach and remove the varicosities. The results are not great and the recovery is prolonged.
Other surgical approaches have involved removal of all adhesions in the pelvis, anatomic corrections of the displaced uterus and even hysterectomy.
What are the results after surgery?
Even after the complete removal of the uterus and surrounding blood vessels, the results are not optimum and some women continue to have the same symptoms. So before one jumps into surgery, always get a second opinion and even then, think again.
What is embolization?
In the last decade, there has been a new radiological method of treating PCS called embolization. Embolization is only undertaken after the diagnosis is confirmed. Basically it involves plugging the blood vessels so that they do not become engorged with blood anymore, and the varicosities subside with time. The procedure is typically done by an interventional radiologist and takes a few hours. It does not require any anesthesia. There is significant pain, nausea and even fever the first few days after the procedure. The procedure requires an overnight stay in the hospital.
What are the results of embolization for pelvic congestion syndrome?
The results are still conflicting and scant. Despite the varicosities diminishing, not all women improve. At best, less than 60 percent of women claim to feel better after the procedure. However, the pain improvement is not immediate and may take 2-4 weeks. Other may require multiple sessions. The success of the therapy depends on the degree of varicosities and the symptoms prior to the procedure. One should be note that not all patients have a response and some continue to have the symptoms.
What are the advantages of embolization versus surgery?
- Minimally invasive: there is no large incision and the downtime is minimal. In addition, the procedure is not associated with all the possible complications that can occur after surgery and anesthesia.
- Anesthesia: there is no need for general anesthesia with embolization.
- Symptoms control: More patients appear to benefit from embolization compared to surgery. In those individuals who benefit, the symptoms are relieved for several years.
What are risks of embolization?
- Vessel injury: when the needle is placed in the groin, there can be damage to the vessel, bleeding or bruising at the puncture site.
- Allergy: The dye used during the procedure is known to cause allergy. Prior to undergoing the procedure, all individuals should divulge any history of allergies.
- Failed procedure: Occasionally, some individuals may not respond despite a successful embolization.
- Radiation exposure: The procedure is associated with radiation exposure and may not be suitable for pregnant females.
PCS is a difficult disorder both in terms of diagnosis and treatment. The vague symptoms and variable intensity of pain do not all respond to one treatment. All types of treatments have been recommended and currently, embolization is the preferred therapy. However, before one embarks on any therapy, read and understand the disorder and talk with a reputable physician or radiologist.