Answer for BIR CoW 01 Aug 2021
Pelvic congestion syndrome
Findings
CECT abdomen (delayed phase) shows multiple prominent pelvic veins – more on the left side. On DSA, contrast injected through the right femoral vein approach shows normal right internal iliac, external iliac and common iliac veins and normal right external iliac venography with antegrade flow into Inferior Vena Cava. Selective injection into right internal iliac vein shows minimal reflux into pelvic veins. Contrast injection into left internal iliac vein in the early phase shows dilated tortuous left ovarian vein (arrow) and pelvic veins (arrow head). Also, there is retrograde flow into pelvic veins seen initially with delayed contrast clearance into IVC. Selective injection into left Gonadal vein reveals dilated tortuous left ovarian vein from left renal vein with retrograde filling of pelvic veins.
Discussion
Pelvic congestion syndrome (PCS) is a common cause of chronic lower abdominal/pelvic pain, estimated to affect about 10–15 % of women, predominantly between the ages of 30 and 45 . PCS is anatomically characterized by the presence of varicose and incompetent parametrial veins. In the majority of patients, PCS manifests with non-cyclic abdominal or pelvic pain lasting for at least half a year. Other symptoms include vulvar swelling, lower limb edema and urinary urgency. Women with PCS are typically premenopausal, and a relationship between PCS and endogenous oestrogen levels has been suggested, since oestrogen is known to weaken vein walls The preferred imaging study for PCS is transvaginal ultrasound (TVUS) with Doppler imaging, which enables dynamic visualisation of the flow in pelvic venous plexus. The unaffected pelvic veins are relatively straight structures with a diameter less than 4 mm. In patients with PCS, ultrasound findings commonly include parametrial venous plexus dilation above 6 mm and slow or reversed blood flow during Valsalva manoeuvre. The possibility of oestrogen overstimulation in women with PCS may explain why more than 50 % also have cystic ovaries as observed during TVUS Endovascular diagnosis of PCS is based on venography, which remains a highly effective modality. Diagnostic venography offers a direct imaging of the blood reflux into varicose plexus. It provides information about dynamic flow and accurate measurements of the ovarian and internal iliac veins. Venographic findings in PCS :The diagnosis of PCS is confirmed with the following venographic findings: ovarian vein diameter > 6 mm in diameter, retrograde ovarian or pelvic venous flow, presence of several tortuous collateral pelvic venous pathways, delayed or stagnant clearance of contrast at the end of injection. Treatment –Embolization of engorged pelvic veins The transjugular or subclavian routes offer the most reliable access to all major relevant pelvic veins from a single puncture site. Sedoanalgesia utilizing an opiate and a benzodiazepine together with an antiemetic, although there is no absolute requirement for ‘conscious sedation’ as the procedure is well tolerated. In contrast to conventional ‘open’ or laparoscopic surgical techniques, endovenous procedures use a minimally invasive approach to occlude and ultimately ablate refluxing veins . However, physical media such as extreme heat (e.g. radiofrequency, laser, steam) used in treating refluxing ‘peripheral’ veins are inadvisable for use in the abdomen or pelvis given the proximity of visceral structures such as bowel and ureter, which may be irreversibly damaged. The commonest embolic agents utilized are platinum embolization coils, foam, glue and liquid sclerosants [e.g. Polidocanol, 3 % sodium tetradecyl sulphate (STS)].
Findings
CECT abdomen (delayed phase) shows multiple prominent pelvic veins – more on the left side. On DSA, contrast injected through the right femoral vein approach shows normal right internal iliac, external iliac and common iliac veins and normal right external iliac venography with antegrade flow into Inferior Vena Cava. Selective injection into right internal iliac vein shows minimal reflux into pelvic veins. Contrast injection into left internal iliac vein in the early phase shows dilated tortuous left ovarian vein (arrow) and pelvic veins (arrow head). Also, there is retrograde flow into pelvic veins seen initially with delayed contrast clearance into IVC. Selective injection into left Gonadal vein reveals dilated tortuous left ovarian vein from left renal vein with retrograde filling of pelvic veins.
Discussion
Pelvic congestion syndrome (PCS) is a common cause of chronic lower abdominal/pelvic pain, estimated to affect about 10–15 % of women, predominantly between the ages of 30 and 45 . PCS is anatomically characterized by the presence of varicose and incompetent parametrial veins. In the majority of patients, PCS manifests with non-cyclic abdominal or pelvic pain lasting for at least half a year. Other symptoms include vulvar swelling, lower limb edema and urinary urgency. Women with PCS are typically premenopausal, and a relationship between PCS and endogenous oestrogen levels has been suggested, since oestrogen is known to weaken vein walls The preferred imaging study for PCS is transvaginal ultrasound (TVUS) with Doppler imaging, which enables dynamic visualisation of the flow in pelvic venous plexus. The unaffected pelvic veins are relatively straight structures with a diameter less than 4 mm. In patients with PCS, ultrasound findings commonly include parametrial venous plexus dilation above 6 mm and slow or reversed blood flow during Valsalva manoeuvre. The possibility of oestrogen overstimulation in women with PCS may explain why more than 50 % also have cystic ovaries as observed during TVUS Endovascular diagnosis of PCS is based on venography, which remains a highly effective modality. Diagnostic venography offers a direct imaging of the blood reflux into varicose plexus. It provides information about dynamic flow and accurate measurements of the ovarian and internal iliac veins. Venographic findings in PCS :The diagnosis of PCS is confirmed with the following venographic findings: ovarian vein diameter > 6 mm in diameter, retrograde ovarian or pelvic venous flow, presence of several tortuous collateral pelvic venous pathways, delayed or stagnant clearance of contrast at the end of injection. Treatment –Embolization of engorged pelvic veins The transjugular or subclavian routes offer the most reliable access to all major relevant pelvic veins from a single puncture site. Sedoanalgesia utilizing an opiate and a benzodiazepine together with an antiemetic, although there is no absolute requirement for ‘conscious sedation’ as the procedure is well tolerated. In contrast to conventional ‘open’ or laparoscopic surgical techniques, endovenous procedures use a minimally invasive approach to occlude and ultimately ablate refluxing veins . However, physical media such as extreme heat (e.g. radiofrequency, laser, steam) used in treating refluxing ‘peripheral’ veins are inadvisable for use in the abdomen or pelvis given the proximity of visceral structures such as bowel and ureter, which may be irreversibly damaged. The commonest embolic agents utilized are platinum embolization coils, foam, glue and liquid sclerosants [e.g. Polidocanol, 3 % sodium tetradecyl sulphate (STS)].
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!