Transvaginal ultrasound examination of women with and without pelvic venous congestion

A scoping review of scores or grading systems for pelvic venous disorders

BACKGROUND

Pelvic venous disorders (PeVD) encompass a variety of conditions linked to chronic pelvic pain in women. However, PeVD remain underdiagnosed due to the absence of universally accepted diagnostic criteria. The complexity of PeVD classifications across specialties leads to delays in treatment. This scoping review aims to fill a gap in PeVD diagnosis and management by identifying all existing scoring or grading systems to lay the foundation for standardized clinical scoring tools for PeVD.

METHODS

This scoping review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews. Online databases were searched up to April 2023. Studies implementing a scoring or grading system for patients with confirmed or suspected PeVD were included. Scores or grading systems were classified into four main categories based on their use in the study: screening, diagnosis, measure of disease severity, and measure of response to treatment.

RESULTS

Of the 2976 unique records identified, 82 were reviewed in full, and 20 were included in this study. The publication dates ranged from 1984 to 2023 (median, 2018; interquartile range, 2003-2022). A total of 21 scores and/or grading systems were identified. Of these 21 scores, 10 (47.6%) were clinical scores, and 10 (47.6%) were scores based on radiological findings; one study included a score that used both clinical and radiological findings. The identified scores were used in various settings. Of the 21 scores, 2 (9.52%) were used for screening in a tertiary care setting; 3 (14.3%) were used to establish the PeVD diagnosis; 8 (38.1%) were used to assess disease severity; and 8 (38.1%) were used as measures of response to treatment. Of the eight scores assessing disease severity, four (50.0%) assessed the degree of dilatation of pelvic veins and four (50%) assessed the severity of reflux. Only three of the scores were validated.

CONCLUSIONS

This scoping review identified a range of scoring and grading systems for PeVD. We note a lack of a validated scoring system, both clinical and radiological, for screening and assessment of disease severity. This is an important first step in developing validated disease-specific scoring systems for patient screening, appropriate referral, assessment of symptom severity, and assessment of the response to treatment.

Reference ranges for uterine vein dimensions in non-pregnant women with normal pelvic organs

OBJECTIVE

To establish reference ranges for uterine vein (UtV) diameters in non-pregnant women with normal pelvic organs.

METHODS

This was a prospective study of all women attending the general gynecological clinic of a university teaching hospital in the UK, between August 2015 and December 2016. All women aged ≥ 18 years underwent a transvaginal ultrasound examination in accordance with the study protocol. In women with normal pelvic organs, the largest trunk of the uterine venous plexus was identified in the transverse plane on each side. The maximum anteroposterior vessel diameter was measured by placing the calipers on the inner walls of the vein, and the mean of three measurements was used as the representative value. Inter- and intraobserver variability was assessed in a subgroup of 30 women. Maximum UtV diameter was compared between right and left UtVs and between pre- and postmenopausal women. Factors associated with UtV diameter were assessed and reference ranges were constructed.

RESULTS

Of 1500 women examined, 486 (32%) had normal pelvic organs on ultrasound scan and were included in the final analysis. In all women, the uterine venous trunk was clearly visualized and there was no significant difference between the maximum median left and right UtV diameters (P = 0.37). UtV diameters were generally lower in postmenopausal, compared with premenopausal, women, with the difference being statistically significant for the right UtV and the average of left and right UtVs. There was a gradual increase in UtV diameter with advancing age, with a peak observed in women aged 41-50 years and decreasing values in older age groups. Univariable analysis showed that parity, menopausal status and age were associated significantly with UtV diameters (P < 0.01). On multivariable analysis, only higher parity was significantly associated with increasing venous size in both pre- and postmenopausal women. Reference ranges were constructed separately for nulliparous and parous premenopausal women aged between 18 and 45 years.

CONCLUSION

UtVs can be identified and measured consistently in all women with normal pelvic organs using transvaginal ultrasound. Parity was the main factor influencing the maximum mean UtV diameter, which had to be taken into account when constructing reference ranges. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review

Introduction

In the work‐up of patients with suspected pelvic congestion syndrome, venography is currently the gold standard. Yet if non‐invasive diagnostic tools are found to be accurate, invasive venography might no longer be indicated as necessary.

Material and methods

A literature search in Pubmed and EMBASE was performed from inception until 6 May 2017. Studies comparing non‐invasive diagnostic tools to a reference standard in the work‐up of patients with (suspected) pelvic congestion syndrome were included. Relevant data were extracted and methodological quality of individual included studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool.

Results

Nine studies matched our inclusion criteria. Six studies compared ultrasonography to venography and three studies described a magnetic resonance imaging technique. In using transvaginal ultrasonography, the occurrence of a vein greater than five mm crossing the uterine body had a specificity of 91% (95% CI; 77–98%) and occurrence of pelvic varicoceles a sensitivity and specificity of 100% (95% CI; 89–100%) and 83–100% (95% CI; 66–93%), respectively. In transabdominal ultrasonography, reversed caudal flow in the ovarian vein accounted for a sensitivity of 100% (95% CI; 84–100%). Detection of pelvic congestion syndrome with magnetic resonance imaging techniques resulted in a sensitivity varying from 88 to 100%.

Conclusions

The sensitivity of ultrasonography and magnetic resonance imaging seem to be adequate, which indicates a role for both tests in an early stage of the diagnostic workup. However, due to methodological flaws and diversity in outcome parameters, more high standard research is necessary to establish a clear advice for clinical practice.

Pelvic vein incompetence: clinical perspectives

Chronic pelvic pain (CPP) affects 24% of premenopausal women, accounts for 20%-30% of UK gynecology outpatient appointments, and has an annual pan-European economic cost of €3.8 billion. Despite extensive investigation, often including laparoscopy, up to 55% of women do not receive a diagnosis and endure persistent symptoms. In these patients, clinical management focuses on symptom control rather than treatment. It is possible that pelvic vein incompetence (PVI) is a cause of CPP, although the quality of studies investigating an association is generally low. PVI may develop during and after pregnancy, as uterine blood flow increases significantly, pushing venous valve leaflets apart, and enabling retrograde venous flow. Analogies with varicose veins of the lower limb are helpful, and symptoms are similar. Women with symptomatic PVI report a dull pelvic ache that is worse on standing and sitting and persists throughout the day. It can be relieved by lying down. Early treatments for PVI included laparoscopic ligation; however, since the advent of endovascular occlusive techniques, treatments have lower risk and lower cost, and can be undertaken without sedation or anesthetic. However, there have been no high-quality randomized controlled trials of interventions and, therefore, the evidence is limited to single-center case series.

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

BACKGROUND

Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited.

OBJECTIVES

Our proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS, the association between PVI and CPP, the accuracy of various non-invasive imaging techniques and the effectiveness of embolisation for PVI; and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research.

DATA SOURCES

A comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases, including MEDLINE, EMBASE and Web of Science. There was no restriction on study design.

METHODS

Methodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively.

RESULTS

We identified six association studies, 10 studies involving ultrasound, two studies involving magnetic resonance venography, 21 case series and one poor-quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found that the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited. Early substantial relief from pain symptoms was observed in approximately 75% of women undergoing embolisation, a figure which generally increased over time and was sustained. Reintervention rates were generally low. Transient pain was a common occurrence following foam embolisation, while there was a < 2% risk of coil migration. Confidence in the embolisation technique is reasonably high, although there is a desire to strengthen the evidence base. Even among women with CPP, fewer than half had any knowledge about PCS.

CONCLUSIONS

The data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology, as the six most pertinent drew on clinically disparate populations and defined PVI inconsistently. Embolisation appears to provide symptomatic relief in the majority of women and is safe. However, the majority of included studies of embolism were relatively small case series and only the randomised controlled trial was considered at risk of potential biases. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and well-powered case-control study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but this faces methodological challenges.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002237 and CRD42012002238.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Evaluation of Effectiveness of Embolization in Pelvic Congestion Syndrome with the New Vascular Occlusion Device (ArtVentive EOS™): Preliminary Results

Purpose

This study aimed to collect confirmatory data in support of the safety and efficiency of the ArtVentive EOS™ for the treatment of the pelvic congestion syndrome (PCS). This study was based on the OCCLUDE 1 Study Protocol approved by the Local Ethics Committee.

Materials and Methods

A prospective study carried out in June and July 2014 included 12 women aged 21–48 years (mean 31 years) scheduled for PCS embolization using the ArtVentive EOS™. The inclusion criteria were clinical symptoms of PCS documented by transvaginal Doppler ultrasound and pelvic MRI. The pelvic pain was assessed by VAS score from 0 to 10 (0 represents lack of pain and 10 unbearable pain). A decrease in pelvic pain intensity based on the VAS was considered a clinical success.

Results

Successful embolization procedures with ArtVentive EOS™ were performed in 11 out of 12 patients. Nine patients underwent unilateral embolization of the left ovarian vein, and two had bilateral embolization of the ovarian veins. Complete ovarian vein occlusion confirmed by post deployment venography was achieved in all 11 patients. Procedures lasted from 19 to 45 min (average 28 min). Pain intensity decrease was observed in all 11 patients—a decrease of 5.6 points—from 7.3 pre-procedure to 1.6 post-embolization (standard deviation: 0.67). In one case, the left ovarian vein was injured by guide wire manipulation with contrast extravasation—not clinically significant.

Conclusions

The use of ArtVentive EOS™ for occlusion of the ovarian veins in PCS patients is safe and effective.

Dolor pélvico en mujeres y el papel de la imágenes diagnósticas

El dolor pélvico es un motivo de consulta frecuente tanto en los servicios  de  consulta  externa  como  de  urgencias,  e implica un reto diagnóstico para  los médicos, especialmente en  el  caso  de las  mujeres,  en  quienes  hay  un  amplio espectro  de diagnósticos  diferenciales  debido  a  las estructuras contenidas que  implican varios sistemas. Con este preámbulo vemos  la necesidad de realizar una revisión de  la  literatura  basada  en  la evidencia  acerca  del  uso adecuado de  las  imágenes diagnósticas en estas patologías para  obtener  los mayores beneficios.  

Using magnetic resonance phase-contrast velocity mapping for diagnosing pelvic congestion syndrome

Objective

To evaluate phase-contrast velocity mapping (PCVM) as a diagnostic tool for pelvic congestion syndrome and comparing this approach with direct venography.

Method

We prospectively include nine women with clinical suspicion of pelvic congestion syndrome during a six-month period. All patients underwent a magnetic resonance phase-contrast scan before a direct venography. We considered a case of pelvic congestion syndrome when the PCVM showed a retrograde or slow (less than 5 cm/second) flow in any gonadal vein. This criterion was compared with the standard diagnostic criterion observed from a direct venography.

Results

Using direct venography we found 14 abnormal veins and all of them were correctly identified by the PCVM. The other four veins were found to be normal by the direct venography. However, two of them (the same patient) were abnormal in the PCVM, even though this patient had the classical symptoms of pelvic congestion syndrome.

Conclusion

PCVM is a useful tool for diagnosing pelvic contrast syndrome and can avoid invasive procedures such as direct venography.

[Place of pelvic ultrasonography using transabdominal technique in the investigation of premature ovarian failure]

OBJECTIVES

The aim of the present study was to characterize women with premature ovarian failure (POF) by their ovarian ultrasonographic appearances using transabdominal technique to establish the relationship to clinical, hormonal status, and genetic analysis.

PATIENTS AND METHODS

We studied a cohort of 80 patients suffering from POF. The surface of the ovary was calculated and we identified the detection or not of follicles.

RESULTS

The detection of the two ovaries by ultrasound was positive in 33 patients; only one ovary was identified in seven patients; none was noted in 40 patients. The surface of the ovaries ranged between 0.74 et 5.92 cm(2) (2.2+/-1.13 cm(2)). Ultrasonography identified follicles in 23 patients (28.75%). The presence of follicles suggested at ultrasonography was detected in 14 cases (70%) in normal-sized ovaries (> or =2 cm(2)) and in nine cases (45%) in small-sized ovaries (p=0.1). No significative statistical difference was found between the ultrasonographic appearances and the type of amenorrhea, pubertal development, hormonal status (estradiol, testosterone and delta-4-androstendione) and the chromosomal analysis.

CONCLUSION

The clinical and hormonal status and the genetic analysis can't predict the presence or not of follicles in the ovaries of patients with POF.

Significance of ovarian histology in the management of patients presenting a premature ovarian failure

BACKGROUND

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or follicles. Based essentially on animal models, these mutations are associated with various ovarian phenotypes, from a complete absence of follicles to a partial follicular maturation. The aim of the present study was to determine whether ovarian histology, compared to pelvic ultrasonography, would be helpful in identifying which patients display an impaired follicular reserve and/or growth, and in orientating the search for POF aetiology.

METHODS AND RESULTS

We studied a cohort of 61 patients suffering from POF with a normal karyotype. Their median age (range) at diagnosis was 26 years (15-39). The FSH plasma level was high, 67.0 IU/l (13-155). Estradiol and inhibin B plasma levels were low: 18.5 pmol/l (18.5-555) and 5 pg/ml (5-105) respectively. Both pelvic ultrasonography and ovarian biopsies were performed in each patient. The presence of follicles suggested at ultrasonography was confirmed at histology in 56% of the patients. Ovarian histology led to the distinction of two phenotypes: (i) small-sized ovaries, deprived of follicles; and (ii) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women were studied. These demonstrated that ovarian biopsy at random enables reliable assessment of follicular presence, especially when their size is <2 mm.

CONCLUSION

Ovarian histology appears to be a reliable tool in evaluating the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in orienting the search for the various genetic causes of POF syndrome.

Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome

STUDY OBJECTIVE

To evaluate the efficacy and safety of bilateral laparoscopic transperitoneal ligation of the ovarian veins in women with symptomatic pelvic varices.

DESIGN

Prospective pilot study performed in a small series (Canadian Task Force classification III).

SETTING

Urban hospital in Turin and University hospital in Cagliari, Italy.

PATIENTS

Twenty-three women.

INTERVENTION

Bilateral laparoscopic transperitoneal ligation of the ovarian veins. The right ovarian vein was reached by incising posterior peritoneum below the mesentericoparietal fossa in all women. The left ovarian vein was reached by reflecting medially the left colon in 10 women and by incising the posterior peritoneum covering the aorta 2 cm below the inferior duodenal fold in 13.

MEASUREMENTS AND MAIN RESULTS

After the plateau of the learning curve was reached, average operating time was about 60 minutes without complications. Complete remission of pain and absence of pelvic varicosities lasted for 12 months.

CONCLUSION

The laparoscopic transperitoneal paraaortic approach to bilateral ligation of ovarian veins near their origin could be a new treatment option for pelvic congestion syndrome.

Transvaginal power Doppler ultrasound in pelvic congestion

PURPOSE

Pelvic congestion is diagnosed by transuterine venography, an invasive procedure requiring sedation and irradiation. Ultrasound may be an alternative but is hindered by slow flow within pelvic veins. In an attempt to counter this, we investigated the possible role of transvaginal power Doppler ultrasound.

MATERIAL AND METHODS

42 women with a clinical suspicion of pelvic congestion underwent transvaginal ultrasound. Adnexal veins were examined and a congestion score established. Planimetric measurements of adnexal vessels were obtained using power Doppler ultrasound, and uterine and ovarian morphology noted. All women then underwent transuterine venography and agreement with the ultrasound congestion score and morphologic features was determined.

RESULTS

There was a trend towards weak positive correlation between ultrasound and venography congestion scores (r = 0.29, p = 0.06). However, agreement between scores was poor on an individual basis (95% limits of agreement, -3.9 to +2.7). Planimetric power Doppler assessments of adnexal vascularity were unrelated to venographic congestion. Instead, there was correlation between the number and diameter of ovarian follicles and venographic congestion: women with congestion tended to have significantly more (0.04) and smaller follicles (p = 0.001).

CONCLUSION

There was poor individual agreement between ultrasound and venographic estimates of congestion. However, there was a direct relationship between venographic congestion score and ovarian morphology.