Correlation between pelvic congestion syndrome and body mass index

A comprehensive ultrasound approach to lower limb varicose veins and abdominal-pelvic connections

OBJECTIVE

Pelvic venous reflux may be responsible for pelvic venous disorders and/or lower-limb (LL) varicose veins. Ultrasound investigation with Doppler allows a complete study of the entire infra-diaphragmatic venous reservoir. The aim of this study was to guide and standardize the investigation of the pelvic origin of venous reflux in female patients with LL varicose veins.

METHODS

In this case-control study, we applied a comprehensive ultrasound investigation protocol, which involved four steps: (1) venous mapping of the lower limbs; (2) transperineal and vulvar approach; (3) transabdominal approach; and (4) transvaginal approach.

RESULTS

Forty-four patients in group 1 (patients with LL varicose veins and pelvic escape points [PEPs]) and 35 patients in group 2 (patients with LL varicose veins without PEPs [control group]) were studied, matched by age. The median age was 43 years in both groups. The calculated body mass index was lower in group 1 (23.4 kg/m2) compared with the control group (25.4 kg/m2), and this difference reached statistical significance (P < .001). The presence of pelvic varicose veins (PVs) by transvaginal ultrasound was 86% in group 1 and 31% in group 2. Perineal PEPs were the most prevalent, being found in 35 patients (79.5%), more frequent on the right (57.14%) than on the left (42.85%) and associated with bilateral PVs 65.7% of the time. In group 1, 23 patients (52%) reported recurrent varicose veins vs eight patients (23%) in the control group (P = .008). Regarding the complaint of dyspareunia, a significant difference was identified between the groups (P = .019), being reported in 10 (23%) patients in group 1 vs one patient (2.9%) in the control group. The median diameters in the transabdominal approach of the left gonadal veins were 6.70 mm for group 1 and 4.60 mm for group 2 (P < .001). In patients with PVs in group 1, the median diameter of PEPs at the trans-perineal window was 4.05 mm. In the transvaginal examination, the mean diameter of the veins in the peri uterine region was 8.71 mm on the left and 7.04 mm on the right.

CONCLUSIONS

The identification of PEPs by venous mapping demonstrates the pelvic origin of the reflux and its connections with the LL varicose veins. For a more adequate treatment plan, we suggest a complete investigation protocol based on the transabdominal and transvaginal study to rule out venous obstructions, thrombotic or not, and confirm the presence of varicose veins in the pelvic adnexal region.

A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome

Pelvic congestion syndrome (PCS) in females and varicoceles in males may be regarded as closely related conditions since the main pathophysiological cause for both processes is pelvic venous insufficiency. Varicoceles are more prevalent amongst sub-fertile males, with an approximate incidence of 15% in the general male population. PCS is commonly diagnosed amongst premenopausal multiparous women, representing one of the leading causes of chronic pelvic pain. Both conditions appear to be predominantly left-sided and are associated with oxidative stress and pro-inflammatory cascades with subsequent effects on fertility. Clinical examination and pelvic ultrasonography play an essential role in the assessment of varicoceles, PCS and chronic pelvic pain. Venography is generally considered as a gold-standard procedure for both conditions. There is still much debate on how these conditions should be managed. This review article provides a comparative analysis of the underlying pathophysiological mechanisms of both PCS and varicoceles, their impact on fertility, as well as their clinical management.

Comprehensive overview of the venous disorder known as pelvic congestion syndrome

Pelvic venous disorders (PeVD) also known as Pelvic Congestion Syndrome (PCS) affect a great number of women worldwide and often remain undiagnosed. Gynecological symptoms caused by vascular background demand a holistic approach for appropriate diagnosis. This is a relevant cause of chronic pelvic pain and atypical varicose veins. The diagnosis is based on imaging studies and their correlation with clinical presentation. Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation. The following paper describes an in-depth overview of anatomy, pathophysiology, symptoms, diagnosis and treatment of PCS. In recent years, minimally invasive interventions have become the method of first choice for the treatment of this condition. The efficacy of a percutaneous approach is high and it is rarely associated with serious complications.Key MessagesPelvic venous disorders demand a holistic approach for appropriate diagnosis.This article takes an in-depth look at existing therapies of Pelvic Congestion Syndrome and pathophysiology of this condition.Embolisation is an effective and safe treatment option.

Prevalence of left iliac vein compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis: A multicenter cross-sectional study in southern China

OBJECTIVE

Population-based epidemiological data on left common iliac vein (LCIV) compression is scarce. This study aimed to investigate the prevalence of LCIV compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis (IF-DVT).

MATERIALS AND METHODS

Nonprobability sampling method was used in this multicenter cross-sectional study. The minimum diameter of LCIV and right common iliac vein minimum were measured. The percentage of LCIV compression (LCIV-CP) was calculated. Compression severity (CS) was classified as mild (CP ≤ 50%), moderate (50% < CP ≤ 70%), and severe (CP > 70%).

RESULTS

In all, 896 subjects constituted the asymptomatic population and 93 patients constituted the IF-DVT population. In the asymptomatic population, LCIV-CP ranged from 1.1% to 89.9% (mean 44.0%), and people with mild, moderate, and severe CS accounted for 62.3%, 28.2%, and 9.5%, respectively. In the IF-DVT population, the mean LCIV-CP was 71.1% (range 42.2%-95.2%), and patients with severe CS accounted for 75.3%. Gender and age differences in LCIV-CP and CS distribution were observed in the asymptomatic population. Females, the young- and middle-aged group had higher LCIV-CPs. In the population with moderate-severe CS, the middle-aged group accounted for a larger proportion. Middle-aged females comprised the highest percentage of patients with moderate or severe CS. Sex and age affected the LCIV-CP and CS distribution. No gender and age differences were observed in the IF-DVT population.

CONCLUSIONS

LCIV compression is common in population. Middle-aged females are the predominant population with moderate-severe compression. Overlapping of LCIV-CP in the asymptomatic and IF-DVT population is significant and other risk factors should be integrated into the consideration when assessing the risk of IF-DVT secondary to LCIV compression.

Pelvic Pain in Reproductive Age: US Findings

Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too. The didactic objective proposed by this review consists in the diagnosis of the cause and differential of pelvic pain in reproductive age by describing and critically analyzing the US diagnostic clues of the most frequent adnexal, uterine, and vascular causes.

Predicting pelvic congestion syndrome: Concomitant pelvic pain diagnoses do not affect venography or embolization outcomes

Objectives

Pelvic congestion syndrome (PCS) is a challenging diagnosis to make secondary to nonspecific presenting symptoms and imaging findings. This retrospective review aims to discern predictive factors which can guide the decision to perform catheter-based venography and prognosticate outcomes.

Material and Methods

A retrospective analysis of patients who underwent catheter venography for PCS between January 2014 and December 2019 was performed. Multiple factors, including patient demographics, clinical history, pre-procedural imaging, venographic findings, and treatment outcomes 180 days post-procedure, were included in the analysis. Venographic findings were used to separate patients into two groups (positive or negative), with these factors compared across groups. Regression analysis controlled for the confounding effects of age and body mass index (BMI). Treated subjects were separated based on outcome (partial, no response, complete response, or technical failure), and comparisons were performed.

Results

Eighty patients were included in the initial analysis. Two patients were excluded due to prior embolization or portal hypertension. Seventy-eight patients were included in the final analysis. Sixty-two patients had positive findings, and 16 had no venographic findings to suggest PCS. A history of prior pregnancy was a significant predictor of positive venographic results (odds ratio = 5.99, P = 0.007). BMI was significantly lower in those with positive venographic results (P = 0.047). Presence of concomitant diagnoses did not affect venographic findings or treatment outcomes. No factors predicted treatment outcomes. Five of the treated patients had subsequent successful pregnancies.

Conclusion

A lower BMI supports the decision to perform venography for suspected PCS. In addition, patients who carried concomitant potentially confounding diagnoses for chronic pelvic pain were found to have similar rates of venographic findings suggesting PCS, as well as similar treatment outcomes.

Sonographic Evaluation of Pelvic Venous Disorders

ABSTRACT

Pelvic venous disorders are a group of interrelated conditions characterized by venous incompetence. These conditions often manifest with nonspecific symptoms that overlap with many gynecological, gastrointestinal, and urologic diseases. Clinical diagnosis can be difficult, and imaging can play a vital role in differentiating etiology. Sonographic evaluation is often the first step in evaluating these symptoms. Special attention to possible underlying pelvic venous disorders can reveal characteristic findings, support diagnosis, and guide treatment. Here we review pelvic congestion syndrome, nutcracker syndrome, May-Thurner syndrome, and other venous disorders, with a specific focus on sonographic findings and considerations.

Stratification of pelvic venous reflux in patients with pelvic varicose veins

OBJECTIVE

We investigated the association between the pattern and duration of pelvic venous reflux (PVR) and pelvic pain severity in patients with pelvic varicose veins (PVVs).

METHODS

The present retrospective study included 600 female patients with PVVs. Of the 600 patients, 453 had had PVVs and pelvic congestion syndrome (group 1) and 147 had had an asymptomatic disease course (group 2). Pelvic venous pain (PVP) was assessed using a visual analog scale. All the patients had undergone duplex ultrasound of the left and right renal veins, external, internal, and common iliac veins, and parametrial, uterine, gonadal, and vulvar veins (PV, UV, GV, and VV, respectively), with an assessment of their patency and diameter and the presence and duration of reflux. Reflux in the pelvic veins was considered pathologic if it lasted for >1 second.

RESULTS

In group 1, PVR type I (1-2 seconds), II (3-5 seconds), and III (>5 seconds or spontaneous reflux in the absence of a loading test) was found in 31%, 58%, and 11% of the patients, respectively. Moderate and severe reflux (types II and III) was associated with severe PVP (mean score, 8.3 ± 0.5) in 69% of the group 1 patients. A combination of reflux in the GV, PV, UV, and internal iliac vein was associated with severe PVP (mean score, 8.1 ± 0.3) in 51% of these patients. A combination of reflux in the PVs, UVs, and VVs was associated with moderate pain (mean score, 5.3 ± 0.2) in 49.2% of group 1. In group 2, PVR type I, II, and III was present in 95%, 4%, and 1% of the patients, respectively, and was observed in the PV only in patients with type I; in the GVs, PVs, UVs, and internal iliac veins in those with type II; and in the PVs and GVs in the patients with type III reflux. Reflux in the GVs and UVs was significantly more prevalent in group 1 than in group 2 (GVs, 51% vs 6%; P = .0001; UVs, 57% vs 7%; P = .0001). A combination of reflux in the GVs and UVs was a predictor of severe PVVs (odds ratio, 19.7; 95% confidence interval, 11.3-34.6).

CONCLUSIONS

In patients with PVVs, the presence and severity of pelvic pain will be determined by the type of PVR and its distribution in the pelvic veins. The combination of moderate to severe reflux (types II and III) in the PVs, UVs, and GVs was a predictor of severe PVP. Patients with asymptomatic PVVs were characterized by mild reflux (type I) in the PVs, with rare involvement of the GVs and UVs.

Vulvar Varicosities in an Adolescent Girl with Morbid Obesity: A Case Report

Vulvar varicosities in nonpregnant females, either isolated or as a part of the pelvic congestion syndrome, are rare. We present a case of an adolescent girl with morbid obesity with bilateral bluish protrusions on the labia minora, as an incidental finding, that coincided with her excessive weight gain. The adolescent underwent thorough clinical examination, doppler ultrasound, contrast venography and varicography, and magnetic resonance angiography to rule out alternative diagnoses. Imaging results confirmed the presence of large venous lakes. Venous drainage to the internal iliac vein and connections with the long saphenous vein were delineated. Incompetence, dilatation, or reflux of ovarian or internal iliac veins, or their main tributaries, were not noted. Since the adolescent was asymptomatic and other pathologies, such as vascular malformations or hemangiomas were excluded, she was managed conservatively with counseling about lifestyle modification and weight reduction. This is only the third reported case of vulvar venous varicosities in adolescents. Female sex, along with obesity, are known risk factors for varicose vein formation; however, the pathogenesis is not fully understood. Additional research is needed to elucidate the role of excess adipose tissue in the pathophysiology of vulvar varicose veins and to optimize diagnostic workup and management in adolescence.

Pelvines Stauungssyndrom: Wie wird die Diagnose gesichert, wer muss behandelt werden?

Unterleibsbeschwerden waren lange Zeit die Domäne von Gynäkologen, Internisten und Urologen. Die Erkenntnis, dass auch eine venöse Abstrombehinderung im kleinen Becken bzw. im Abdomen ähnliche Beschwerden hervorrufen kann, hat dazu geführt, dass in den letzten Jahren auch Gefäßmediziner in die Diagnostik und Behandlung einbezogen werden.

Das pelvine Stauungssyndrom kann eine Vielzahl von auch nichtspezifischen Beschwerden verursachen. Die differenzialdiagnostische Abgrenzung zu gynäkologischen, internistischen oder auch orthopädischen Störungen stellt damit eine Herausforderung dar. Die akribische Anamneseerhebung und Symptombeschreibung sind von übergeordneter Bedeutung. In der weiteren Diagnostik kommt der Sonografie die wichtigste Bedeutung zu, die durch radiologische Schichtbildverfahren ergänzt werden kann. Wird vor allem eine Varikose im Genitalbereich beklagt, ist zu klären, ob es sich um eine venöse Insuffizienz im Bereich der Vena iliaca interna bzw. der Vena ovarica handelt oder ob postthrombotische Veränderungen eine Rolle spielen. Bei pelvinen und abdominellen Schmerzzuständen müssen zusätzlich die Nierenvenen und die untere Hohlvene beurteilt werden.

Nur wenn die Störung differenzialdiagnostisch sicher abgegrenzt werden kann, ist eine invasive Behandlung durch Katheterverfahren und/oder Schaumsklerotherapie angezeigt.

The Effect of a Subsequent Pregnancy After Ovarian Vein Embolization in Patients with Infertility Caused by Pelvic Congestion Syndrome

RATIONALE AND OBJECTIVES

To report the effect of pregnancy on patients who have undergone pelvic vein embolization with pelvic congestion syndrome, which was suspected to be the only cause of infertility.

MATERIAL AND METHODS

Data from a total of 12 women (mean age: 36.5 ± 4.3 years, range: 29-45 years) were collected between May 2013 and June 2016. Transvenous embolization with fibre platinum coils combined with anhydrous alcohol was performed in unilateral or bilateral ovarian veins after the diagnosis of venous varices confirmed by transvaginal ultrasound or pelvic venography. The follow-up time was 2-3 years. The primary outcomes of this study were the technical procedure and clinical effect, especially the pregnancy rate and complications.

RESULTS

The successful embolization rate was 100% with no significant complications during or after embolization. Ovarian vein embolization was performed unilaterally (7/12, 58.3%) or bilaterally (5/12, 41.7%). A total of 66.7% (8/12) of women had a subsequent pregnancy and complete pelvic pain relief, and 33.3% (4/12) of patients had partial pain relief. The numeric pain perception scores improved from 6.7 ± 1.1 to 2.7 ± 1.2 (p < 0.001).

CONCLUSION

Ovarian varices may be associated with infertility in some patients, and embolization of ovarian varices is a safe and effective method for those trying to become pregnant.

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.