Chronic Pelvic Pain: Pelvic Venous Disorder or Pelvic Congestion Syndrome

For the past three years,K,35, had been suffering from lower abdominal discomfort and backache after the birth of her second child. The pain was worse on the first 2 days of menstruation. It was aggravated by prolonged standing and exercise but was relieved when she lay down especially in a prone position. The menstrual pain was accompanied by abdominal bloating, constipation and frequent urination occasionally. She also experienced pain during sexual intercourse.

She had been seen by many health professionals. Various investigations including endoscopic examinations of the gut (gastroscopy and colonoscopy), bladder (cystoscopy) and reproductive organs(laparoscopy) were normal. Eventually, an MRI of the pelvis revealed that K’s veins in the pelvis were abnormally engorged . K had been suffering from a medical condition called pelvic congestion syndrome or pelvic venous disorder (PVD) .

What is PVD?

PVD is a condition which is characterised by pelvic pain lasting more than 6 months. It is due to engorged varicose veins in the pelvis.

Varicose veins are veins with faulty valves. These valves direct blood flow towards the heart. When they are not functional, blood flows backwards and pools lower down in the veins. Extra blood will pool in the pelvis causing pressure, pain and heaviness in the lower abdomen.

PVD usually affects women of reproductive age. It is rare after menopause.

What causes PVD?

The cause of PVD is not well understood.

It is likely due to hormonal changes in the veins which expand about 50% in size during pregnancy. These changes may cause long-term damage to the walls of the blood vessels, causing veins to remain dilated.

As PVD is uncommon among menopausal women, it is also suggested that female hormone, estrogen, may play a role in making the valves of the vein more susceptible to defects.

What are the risk factors of PVD?

Risk factors include

· Women who have given birth

· Presence of varicose veins elsewhere in the body.

· Family history of varicose veins.

· Polycystic ovarian syndrome (PCOS).

What are the symptoms of PVD?

Symptoms include:

· Pelvic Pain: Dull and achy pain. Occasionally, pain may be sharp and intense. The pain is felt more commonly on the left side. Often, pain starts during or soon after pregnancy.

· Pain is worst

· at the end of the day after prolonged sitting or standing

· during sexual intercourse

· before and during menses.

· Painful or frequent urination

· Frequent bouts of diarrhea and constipation

· Urinary incontinence

How is PVD diagnosed?

Diagnosing PVD can be challenging because many people without pelvic pain can also have dilated veins. As a result, PVD is sometimes underdiagnosed. It is a diagnosis of exclusion, and should be diagnosed after all other causes of pelvic pain have been ruled out.

Various imaging techniques are used for the diagnosis.

Pelvic venography is the gold standard for diagnosing PVD. It is an invasive procedure in which a small catheter is inserted into a vein in either the neck or groin. X-ray is used to guide the catheter into the pelvic veins and dye is injected. Venography shows where the dilated veins are, how the blood is flowing and where the blood is pooling.

Other modalities include ultrasound examination, CT scan and MRI.

How is PVD treated?

Medications that reduce the oestrogen production have been used to relieve pain in PVD, but a more definitive treatment is to block the defective vessels using metal coils or foams by a procedure called embolization. This has a cure rate of 75 to 80 %.

K was referred to the interventional radiologist. She had the embolization procedure done and her pain has since subsided.