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Hannan P, Hansen C, Chatham J, Capen T, Soares B, Wisco JJ, Lin DC. Duplicated and dilated ovarian vein with coexistence of persistent mesonephric artery. Surg Radiol Anat 2024:10.1007/s00276-024-03461-3. [PMID: 39141081 DOI: 10.1007/s00276-024-03461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 08/08/2024] [Indexed: 08/15/2024]
Abstract
During standard cadaveric dissection we encountered multiple vascular variations in the retroperitoneum: duplicated and dilated left ovarian vein with the coexistence of a persistent right mesonephric artery.
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Affiliation(s)
- Patrick Hannan
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Cole Hansen
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Joanna Chatham
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Tyler Capen
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Benjamin Soares
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jonathan J Wisco
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Dustin C Lin
- Department of Anatomy and Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Khilnani NM, Xia JJ, Winokur RS, Meissner MH. Diagnosis and Management of Pelvic Venous Disorders in Women. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03782-1. [PMID: 39009841 DOI: 10.1007/s00270-024-03782-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 06/04/2024] [Indexed: 07/17/2024]
Abstract
Pelvic venous reflux and obstruction can lead to chronic pelvic pain and extra-pelvic varicosities. This paper will discuss the contemporary understanding of this pathophysiology and its clinical manifestations. It will review evidence-based clinical and imaging criteria of pelvic venous disorders, data supporting benefit from venous interventions, criticisms of the available data and highlight evidence research gaps that exist. Finally, it will argue that comparative outcomes research utilizing standardized patient selection for embolization and stenting, embolization treatment strategies that eliminate the pelvic varices (at least to start), and clinically relevant outcome measures are necessary to establish the benefit of vascular treatments.
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Affiliation(s)
- Neil M Khilnani
- Division of Interventional Radiology, Weill Cornell Medicine-NewYork Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA.
| | - Jimmy J Xia
- Division of Interventional Radiology, Weill Cornell Medicine-NewYork Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA
| | - Ronald S Winokur
- Division of Interventional Radiology, Weill Cornell Medicine-NewYork Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA
| | - Mark H Meissner
- Department of Surgery, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
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Patel SE, Chesnut SR. Relationships Among Pelvic Congestion Syndrome Pain, Daily Activities, and Quality of Life. J Obstet Gynecol Neonatal Nurs 2024; 53:416-426. [PMID: 38599242 DOI: 10.1016/j.jogn.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVE To examine women's experiences of pelvic congestion syndrome (PCS) pain. DESIGN Descriptive, cross-sectional. SETTING Online questionnaires in a Facebook PCS support group. PARTICIPANTS Convenience sample of 143 women who self-identified as being diagnosed with PCS. METHODS We recruited women through a social media support group and invited them to participate in a self-reported questionnaire. We collected demographic information and used the McGill Pain Questionnaire to elicit responses related to pain quality, pain intensity, quality of life, and satisfaction with health care. We analyzed data using descriptive statistics and correlation coefficients. RESULTS Respondents characterized their PCS pain as exhausting, stabbing, sharp, shooting, and tender. Respondents indicated that 19 of 24 daily activities increased PCS pain, whereas only 5 reduced PCS pain. Pain intensity was negatively related to the quality of life, health satisfaction, sleep, and sexual relationships. CONCLUSION Chronic pelvic pain from PCS severely affected quality of life among respondents. These findings suggest a difference in the presentation of PCS from historical pain depictions and further highlight the need to identify pain profiles to increase timely and precise diagnosis. Further research is needed to evaluate interventions to increase the quality of life for women with PCS.
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Kavallieros K, Pope T, Mantonanakis K, Tan M, Gianesini S, Lazarashvili Z, Jaworucka-Kaczorowska A, Narayanan S, Gwozdz AM, Davies AH. A scoping review of scores or grading systems for pelvic venous disorders. J Vasc Surg Venous Lymphat Disord 2024:101901. [PMID: 38677550 DOI: 10.1016/j.jvsv.2024.101901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/28/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024]
Abstract
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.
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Affiliation(s)
- Konstantinos Kavallieros
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Tasneem Pope
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Matthew Tan
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | | | | | - Sriram Narayanan
- The Venus Clinic, The Harley Street Heart and Vascular Centre, Singapore, Singapore
| | - Adam M Gwozdz
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Murali N, Gupta R, Desai KR. The role of iliac vein stent placement in pelvic venous disorder management. J Vasc Surg Venous Lymphat Disord 2024; 12:101696. [PMID: 37977520 DOI: 10.1016/j.jvsv.2023.101696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023]
Abstract
Pelvic venous disease (PeVD) has historically been challenging to diagnose and treat. This paper describes a comprehensive approach to the diagnosis of PeVD and reviews the role of iliac vein stent placement in treatment. Patient selection is vital for non-thrombotic iliac vein lesions (NIVLs) as only a small subset of patients with an NIVL will benefit from stent placement. There is limited, inconclusive data on optimal treatment for patients with both primary ovarian vein reflux and an NIVL. Patients with chronic post-thrombotic outflow obstruction typically have a more favorable risk/benefit ratio for intervention but require anticoagulation and close follow-up due to poorer long-term stent patency. Intravascular ultrasound is a useful tool for identifying obstructive lesions, sizing stents, and planning landing zones. More research is needed to characterize underlying pathophysiology, validate thresholds for intervention, develop reliable methods for outcomes assessment, and determine treatment response. Until this data is produced, an individualized treatment approach is warranted.
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Affiliation(s)
- Nikitha Murali
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL
| | - Ramona Gupta
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL
| | - Kush R Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL.
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Shahat M, Abdelbaqy OMA, AbdelHakam AM, Ali SH, Attalla K. Can cross-sectional imaging replace diagnostic venography in pelvic venous disorder (PeVD)? J Vasc Surg Venous Lymphat Disord 2024; 12:101724. [PMID: 38135217 DOI: 10.1016/j.jvsv.2023.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The primary etiology of pelvic venous disorder is multifactorial and challengeable in vascular surgery as it mandates multidisciplinary team cooperation for its evaluation and management. METHODS All patients investigated for pelvic venous disorder in a high-volume, tertiary referral university hospital were identified and analyzed retrospectively during the period (March 2021 through September 2022). Demographic and medical data were scored. Agreement between the noninvasive modalities (computed tomographic venography [CTV] or magnetic resonance venography [MRV]) and diagnostic venography in detecting the refluxing pelvic veins was analyzed. Sensitivity, specificity, and diagnostic accuracy are also measured. No patients' treatments were reported in this study as the treatment is scheduled in other sessions in some cases and is out of the scope of this article. All patients had a diagnostic venogram regardless of the axial imaging modality. The main goal was to compare cross-sectional imaging with diagnostic venography. RESULTS The total number of patients was 120 with a mean age of 34.4 ± 7.1 years; 86.7% were multiparous. All patients presented chronic pelvic pain with vulvoperineal and/or atypical lower limb varicosities. Then patients were divided into two groups: those with CTV and those with MRV. Sensitivity, specificity, and diagnostic accuracy of CTV were 50%, 33%, and 47% for the detection of incompetent ovarian veins, 83%, 33%, and 53% for the detection of incompetent internal iliac veins, and 50%, 40%, and 47% for the detection of incompetent pelvic plexus veins, respectively, whereas time-resolved MRV achieved sensitivity, specificity, and diagnostic accuracy of 73%, 25%, and 60% for the detection of incompetent ovarian veins, 75%, 46%, and 53% for the detection of incompetent internal iliac veins, and 67%, 33% and 60% for detection of incompetent pelvic plexus veins, respectively. CONCLUSIONS The desire to avoid the drawbacks of diagnostic venography led to an increase in the use of noninvasive imaging modalities. Our results achieved acceptable sensitivity, specificity, and diagnostic accuracy outcomes for cross-sectional imaging with the superiority of MRV over CTV in diagnosing PCS.
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Affiliation(s)
- Mohammed Shahat
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt.
| | - Omar M A Abdelbaqy
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Ahmed M AbdelHakam
- Department of Diagnostic and Interventional Radiology, Assiut University Hospitals, Assiut, Egypt
| | - Sahar H Ali
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Khaled Attalla
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
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Hansrani V, Riding D, Seif MW, Caress AL, Payne K, Ghosh J, McCollum CN. Pelvic vein incompetence and chronic pelvic pain: a case-control study. BJOG 2023; 130:1355-1361. [PMID: 37095613 DOI: 10.1111/1471-0528.17485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/10/2023] [Accepted: 03/18/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE To investigate the association between chronic pelvic pain (CPP) and pelvic vein incompetence (PVI) or pelvic varices. DESIGN Case-control study. SETTING Gynaecology and vascular surgery services in two teaching hospitals in north-west England. SAMPLE A total of 328 premenopausal women (aged 18-54 years), comprising 164 women with CPP and 164 matched controls with no history of CPP. METHODS Symptom and quality-of-life questionnaires and transvaginal duplex ultrasound for PVI and pelvic varices. MAIN OUTCOME MEASURES Venous reflux of >0.7 s in the ovarian or internal iliac veins (primary outcome) and presence of pelvic varices (secondary outcome). Statistical analysis compared the prevalence of PVI between women with and without CPP using the two-sided chi-square test. Logistic regression was used to compare the odds of having PVI and pelvic varices between women with and without CPP. RESULTS Pelvic vein incompetence was found on transvaginal duplex ultrasound in 101/162 (62%) women with CPP, compared with 30/164 (19%) asymptomatic controls (OR 6.79, 95% CI 4.11-11.47, p < 0.001). Forty-three of 164 (27%) women with CPP had pelvic varices compared with three of 164 (2%) asymptomatic women (OR 18.9, 95% CI 5.73-62.7, p < 0.001). CONCLUSIONS There was a significant association between PVI, as detected by transvaginal duplex imaging, and CPP. Pelvic varices were strongly associated with CPP and were infrequently seen in control patients. These results justify further evaluation of PVI and its treatment in well-designed research.
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Affiliation(s)
- Vivak Hansrani
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - David Riding
- Manchester Vascular Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mourad W Seif
- St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ann-Louise Caress
- Health Services Research, Department of Nursing and Midwifery, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Katherine Payne
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Jonathan Ghosh
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Charles N McCollum
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
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Shokeir T, Amr M, Abdelshaheed M. Editorial Expression of Concern: The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet 2023; 308:1381. [PMID: 37526687 DOI: 10.1007/s00404-023-07157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Tarek Shokeir
- Fertility Care Unit, Department of Obstetrics and Gynecology, Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt.
| | - Mostafa Amr
- Department of Psychiatry, Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
| | - Mahmoud Abdelshaheed
- Department of Diagnostic Radiology, Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
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De Gregorio MÁ, Yamamoto-Ramos M, Fredes A, Serrano-Casorran C, Sierre S, Ciampi-Dopazo JJ, Méndez S, Abadal JM, Urtiaga I, Bonastre C, Rodríguez J, Urbano J, Guirola JA. A Comparative Study of a Small Series of Patients (50 Patients) with Pelvic Varicose Veins Treated with Plugs Alone or Plugs and Polidocanol. J Clin Med 2023; 12:5408. [PMID: 37629450 PMCID: PMC10455180 DOI: 10.3390/jcm12165408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
LEVEL OF EVIDENCE Level 2. PURPOSE To compare the safety and efficacy of vascular plug (VP) and vascular plug and polidocanol foam (VPPF) treatments for embolization in pelvic congestion syndrome (PCS). MATERIALS AND METHODS A comparative, prospective, two-center study enrolled 50 women with PCS from January 2019 to January 2020. The patients were divided into two groups, and embolization was performed with VP (n = 25) and VPPF (n = 25) treatments. The mean age of the patients was 45.6 years ± 6.9. Three clinical parameters were assessed: abdominal pain, dyspareunia, and lower limb pain. The primary outcome (clinical success at 1 yr using a VAS), number of devices, procedure and fluoroscopy times, radiation doses, costs, and complications were compared. The participants were followed-up at 1, 3, 6, and 12 months. RESULTS At the 1-year follow-up, clinical success did not significantly differ between the two groups (VP vs. VPPF) regarding the improvement of the symptoms analyzed (pelvic pain, dyspareunia, lower extremity pain, and other symptoms (p < 0.05)). The mean number of devices per case was 4 ± 1.1 for the VP group and 2 ± 0.31 for the VPPF group (p < 0.001). No major complications were recorded in either group. The VPPF group had a significantly longer fluoroscopy time (42.8 min ± 14.2 vs. 25.4 min ± 7) and longer radiation dose (VPPF air kerma 839.4 ± 513 vs. VP air kerma 658.4 mGy ± 355 (all p < 0.001)). CONCLUSIONS Embolization for PCS resulted in pain relief in 90% of patients; the use of polidocanol did not demonstrate changes in the clinical outcome. The use of a VP alone was associated with decreased fluoroscopy time and radiation dose.
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Affiliation(s)
- Miguel Ángel De Gregorio
- Minimally Invasive Techniques Research Group—GITMI, University of Zaragoza, Clínica Quirón, 50013 Zaragoza, Spain
| | - Masao Yamamoto-Ramos
- Interventional Radiology, Minimally Invasive Techniques Research Group—GITMI, Clínica Quirón, 50013 Zaragoza, Spain;
| | - Arturo Fredes
- Interventional Radiology, Clinica Quiron Salud Zaragoza, 50006 Zaragoza, Spain;
| | - Carolina Serrano-Casorran
- Minimally Invasive Techniques Research Group (GITMI), University of Zaragoza, 50013 Zaragoza, Spain; (C.S.-C.); (C.B.); (J.R.)
| | - Sergio Sierre
- Interventional Radiology, Hospital Universitario Austral, Buenos Aires B1629, Argentina;
| | | | - Santiago Méndez
- Interventional Radiology, Hospital Universitario Puerta de Hierro, 28222 Madrid, Spain
| | - Jose Maria Abadal
- EBIR Intereventional Radiology, Hospital Universitario Severo Ochoa, 28914 Madrid, Spain;
| | - Ignacio Urtiaga
- Vascular Surgery, Minimally Invasive Techniques Research Group (GITMI), 50013 Zaragoza, Spain;
| | - Cristina Bonastre
- Minimally Invasive Techniques Research Group (GITMI), University of Zaragoza, 50013 Zaragoza, Spain; (C.S.-C.); (C.B.); (J.R.)
| | - Jose Rodríguez
- Minimally Invasive Techniques Research Group (GITMI), University of Zaragoza, 50013 Zaragoza, Spain; (C.S.-C.); (C.B.); (J.R.)
| | - Jose Urbano
- Interventional Radiology, Minimally Invasive Techniques Research Group (GITMI), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - José Andrés Guirola
- Minimally Invasive Techniques Research Group (GITMI), Hospital Clínico Universitario Lozano Blesa, University of Zaragoza, 50009 Zaragoza, Spain;
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Clark MR, Taylor AC. Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment. Semin Intervent Radiol 2023; 40:362-371. [PMID: 37575340 PMCID: PMC10415053 DOI: 10.1055/s-0043-1771041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Pelvic venous disorder (PeVD) is a term that encompasses all the interrelated causes of chronic pelvic pain (CPP) and perineal/lower extremity varicose veins of pelvic venous origin historically known as nutcracker syndrome, pelvic congestion syndrome, and May-Thurner syndrome, resulting in a more precise diagnosis that accounts for the underlying pathophysiology and anatomy. PeVD manifests as CPP with associated vulvar and lower-extremity varicosities, left flank pain and hematuria, and lower extremity pain and swelling secondary to obstruction or reflux in the left renal, ovarian, or iliac veins. This article will focus specifically on the most current nomenclature, evaluation, and management of CPP of venous origin.
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Affiliation(s)
- Meghan R. Clark
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
| | - Amy C. Taylor
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
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Chen H, Wu Z, Wu Z, Huang Q, Ye M, Sun H, Zhang H, Guo P, Zhuang H. Proximal coil occlusion preceding distal sclerotherapy in patients with pelvic congestion syndrome: A multicenter, retrospective study. J Vasc Surg Venous Lymphat Disord 2023; 11:149-155. [PMID: 36183962 DOI: 10.1016/j.jvsv.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/20/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We investigated the efficacy, feasibility, and safety of proximal coil occlusion preceding distal sclerotherapy (PCODS) for patients with pelvic congestion syndrome (PCS). METHODS We performed a multicenter, retrospective cohort study of 94 patients with PCS who had undergone PCODS and 53 patients who had undergone standard endovascular embolization (control group) between June 2014 and April 2020. The primary end point was the clinical remission rate and the secondary end points were the operative time, total fluoroscopy time, radiation dose, overall length of coils used per case, and adverse events. The patients were followed up at 1, 3, 6, and 12 months. RESULTS PCODS was successfully performed in 94 patients (100%). The clinical remission rates were significantly higher in the PCODS group than in the control group at 1, 6, and 12 months (P = .036, P = .032, and P = .032). The operative time and total fluoroscopy time were shorter for the PCODS group than for the control group (48.3 ± 5.2 minutes and 37.7 ± 4.4 minutes vs 53.9 ± 4.8 minutes and 42.6 ± 4.1 minutes, respectively; P < .001 for both). The radiation dose was significantly lower in the PCODS group than in the control group (362,634.69 ± 41,533.13 mGy·cm2 vs 421,578.30 ± 49,517.93 mGy·cm2; P < .001). The overall length of coils used per case was 19.8 ± 6.0 cm in the PCODS group and 31.7 ± 8.5 cm in the control group (P < .001). Migration of n-butyl cyanoacrylate to the renal vein occurred in two patients in the control group. CONCLUSIONS We found PCODS was feasible with a higher clinical remission rate and mild adverse effects in patients with PCS.
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Affiliation(s)
- Hongyu Chen
- Department of Vascular Surgery, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhifen Wu
- Department of Obstetrics and Gynecology, Quanzhou First Hospital, Fujian Medical University, Quanzhou, China
| | - Zhixian Wu
- Department of Hepatobiliary Disease, Dongfang Hospital, School of Medicine, Xiamen University, Fuzhou, China
| | - Qian Huang
- Department of Hepatobiliary Disease, Third People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Minyan Ye
- Department of Hepatobiliary Disease, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Hu Sun
- Department of Vascular Surgery, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, China
| | - Hanyue Zhang
- Department of Hepatobiliary Disease, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Department of Vascular Surgery, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Hui Zhuang
- Department of Vascular Surgery, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen, China.
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Abstract
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.
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Affiliation(s)
- Kamil Bałabuszek
- Department of Radiography, Medical University of Lublin, Lublin, Poland
| | - Michał Toborek
- Department of Radiography, Medical University of Lublin, Lublin, Poland
| | - Radosław Pietura
- Department of Radiography, Medical University of Lublin, Lublin, Poland
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Ford RW, Winokur RS. Pelvic Venous Disorders (PeVD). Semin Intervent Radiol 2022; 39:483-489. [PMID: 36561941 PMCID: PMC9767768 DOI: 10.1055/s-0042-1757938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pelvic venous disorders (PeVDs) have replaced the concept of pelvic congestion syndrome encompassing venous origin chronic pelvic pain (VO-CPP) in women. The evaluation of women with VO-CPP includes the assessment for other causes of pelvic pain as well as imaging evaluation for pelvic varicosities measuring greater than 5 mm diameter, ovarian vein diameter, and flow direction, as well as iliac vein diameter and signs of compression. Proper identification of these patients can lead to high degrees of success eliminating chronic pelvic pain following ovarian vein embolization and/or iliac vein stenting. Strong encouragement is provided to use the symptoms, varices, pathophysiology classification for these patients and upcoming research studies on the specific symptoms of patients with VO-CPP will help elucidate patient selection for intervention. Additional future randomized controlled trials are also upcoming to evaluate for outcomes of ovarian vein embolization and iliac vein.
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Affiliation(s)
- Robert W. Ford
- Division of Interventional Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ronald S. Winokur
- Division of Interventional Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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CARVALHO SFCD, METZGER. PB, FERNANDEZ MG, RIBEIRO WB, NOGUEIRA AKS, SOUZA JPRE. PELVIC VENOUS REFLUX EMBOLIZATION IN THE TREATMENT OF SYMPTOMATIC PELVIC CONGESTIVE SYNDROME: A SYSTEMATIC REVIEW WITH META-ANALYSIS. J Vasc Surg Venous Lymphat Disord 2022. [DOI: 10.1016/j.jvsv.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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15
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Sheikh AB, Fudim M, Garg I, Minhas AMK, Sobotka AA, Patel MR, Eng MH, Sobotka PA. The Clinical Problem of Pelvic Venous Disorders. Interv Cardiol Clin 2022; 11:307-324. [PMID: 35710285 DOI: 10.1016/j.iccl.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.
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Affiliation(s)
- Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Abdul Mannan Khan Minhas
- Department of Internal Medicine, Forrest General Hospital, 6051 US 49, Hattiesburg, MS 39401, USA
| | | | - Manesh R Patel
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Marvin H Eng
- Division of Cardiology, University of Arizona, Banner University Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006, USA
| | - Paul A Sobotka
- The Ohio State University, 281 West Lane Avenue, Columbus, OH 43210, USA.
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Neuenschwander J, Sebastian T, Barco S, Spirk D, Kucher N. A novel management strategy for treatment of pelvic venous disorders utilizing a clinical screening score and non-invasive imaging. VASA 2022; 51:182-189. [DOI: 10.1024/0301-1526/a001001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: Treatment of pelvic venous disorders (PVD) including pelvic congestion syndrome (PCS) are often delayed due to its varying clinical manifestations. Patients and methods: Patient referral was based on a literature- and personal experience-derived clinical “PCS screening score” (higher score points indicate greater likelihood with a maximum score of 10 points). We studied consecutive women who were (i) referred for vascular assessment and treatment to the University Hospital Zurich (2017–2021), (ii) had a PCS score ≥3 points, (iii) had evidence of obstructive or non-obstructive PVD by duplex sonography or cross-sectional imaging, and (iv) underwent endovascular therapy. The primary outcome was change in symptom severity after endovascular therapy: (i) freedom from symptoms, (ii) improvement with residual symptoms, (iii) no improvement. Results: We included 43 women (mean age 36 years): 81% had previous pregnancy, 19% endometriosis. The median PCS score was 7 (IQR 5–9) points. Chronic lower-abdominal pain was the leading symptom in 86% patients, followed by recurrent leg (9%) and vulvar (5%) varicosities. The main PVD pathologies were ovarian vein insufficiency (61%), internal iliac vein insufficiency (9%), or a combination of both (30%), whereas 42% had a deep venous obstruction of the inferior vena cava, common iliac or left renal veins. Endovascular therapy included ovarian vein embolization (86%), internal iliac vein embolization (9%), and venous stent placement (35%). After a median of 4 (IQR 1–8) months from endovascular treatment, 40 (93%) patients reported improvement of the leading symptom, and 14 (33%) were symptom-free. Complications included re-intervention for stent stenosis (13%, all post-thrombotic), coil-migration into the left renal vein (7%, all retrieved), and transient pelvic sclerotherapy-induced thrombophlebitis (2%). Conclusions: Endovascular therapy following a diagnostic approach, which included a PCS screening tool and non-invasive imaging, appeared to be highly effective and was associated with a low rate of complications.
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Affiliation(s)
- Julia Neuenschwander
- Medical Faculty, University of Zurich, Switzerland
- Department of Angiology, University Hospital Zurich, Switzerland
| | - Tim Sebastian
- Department of Angiology, University Hospital Zurich, Switzerland
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Germany
| | - David Spirk
- Institute of Pharmacology, University of Bern, Switzerland
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Switzerland
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Arnaoutoglou C, Variawa RS, Zarogoulidis P, Ioannidis A, Machairiotis N. Advances of Laparoscopy for the Diagnosis of Pelvic Congestion Syndrome. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1041. [PMID: 34684078 PMCID: PMC8539457 DOI: 10.3390/medicina57101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 11/25/2022]
Abstract
The objective of this review is to describe the effectiveness of laparoscopy in the diagnosis and treatment of pelvic congestion syndrome (PCS). PCS is a cause of chronic pelvic pain (CPP) and is associated with dysfunction of the pelvic venous system. PCS is more common in women of reproductive age, and hormonal changes are associated with its development along with other reasons (e.g., working and living habits). There is an urgent need to establish an effective algorithm for the diagnosis and treatment of CPP, which could have a dramatic effect in patients' everyday life. This algorithm should be able to overcome known issues that lead to the underdiagnosis of PCS, such as the overlap of its symptoms with other diseases. Here, we present our findings from literature articles about the methods used in practice today for the diagnosis of this syndrome. We also compare the methods to propose the most promising technique for providing a diagnosis with high accuracy. In our understanding, laparoscopy is superior when compared to other methods. It can provide a diagnosis of PCS while excluding or identifying other comorbidities and can also lead toward the next steps for the treatment of PCS.
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Affiliation(s)
- Christos Arnaoutoglou
- 1st Department of Obstetrics & Gynecology, Papageorgiou Hospital, Aristotle University of Thessaloniki, 57001 Thessaloniki, Greece
| | - Rita S. Variawa
- Independent Pharmacovigilance (Evaluation & Risk Management) Scientist, London E14 4HB, UK;
| | - Paul Zarogoulidis
- 3rd Surgery Department, AHEPA University General Hospital, Aristotle University of Thessaloniki, 57001 Thessaloniki, Greece;
| | - Aris Ioannidis
- Surgery Department, “Genesis” Private Clinic, 57001 Thessaloniki, Greece;
| | - Nikolaos Machairiotis
- Fellow in Endometriosis and Minimal Access Surgery, Northwick Park, Central Middlesex and Ealing Hospitals, Acton Ln, London NW10 7NS, UK;
- London North West University Healthcare NHS Trust, London HA1 3UJ, UK
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A systematic review on isolated coil embolization for pelvic venous reflux. J Vasc Surg Venous Lymphat Disord 2021; 10:224-232.e9. [PMID: 34358670 DOI: 10.1016/j.jvsv.2021.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 07/11/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Pelvic venous reflux (PVR) can present with symptoms such as chronic pelvic pain, dysmenorrhea, and dyspareunia, resulting in a decreased quality of life among those affected. Percutaneous coil embolization (CE) is a common intervention for PVR; however, the efficacy and safety of its use in isolation has yet to be reviewed. METHODS The MEDLINE and EMBASE databases were systematically searched from 1990 to July 20, 2020, for studies reporting on adult patients undergoing isolated CE for PVR. Articles not in English, case reports, studies reporting on pediatric patients, and studies not performing isolated CE were excluded. Search, review, and data extraction were performed by two independent reviewers (S.S. and M.T.). Changes in pain before and after CE was evaluated through a pooled analysis of visual analogue scale scores in seven studies. RESULTS A total of 970 patients (range, 3-218, 100% female) undergoing isolated ovarian vein or mixed veins embolization from 20 studies were included. Pooled analysis revealed mean improvements of 5.47 points (95% CI, 4.77-6.16) on the visual analogue scale. Common symptoms such as urinary urgency and dyspareunia reported significant improvements of 78-100% and 60-89.5% respectively. Complications were rare, with coil migration (n = 19) being the most common. Recurrence rates differed based on the varying symptoms and studies, with recurrence in pain 1-2 years after CE ranging from 5.9-25%. Two randomized controlled trials revealed improved clinical outcomes with CE as compared with vascular plugs and hysterectomy. CONCLUSIONS The current data suggests that isolated CE is technically effective and can result in clinical improvement among patients with PVR. However, further trials are required to ascertain its long-term effects.
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Doganci S. Poorly Understood Pelvic Venous Disorders Require a Multidisciplinary Approach. PHLEBOLOGIE 2021. [DOI: 10.1055/a-1521-5995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractPelvic venous diseases encompasses all chronic pathologies of pelvic veins caused by venous hypertension and retrograde flow in pelvic veins. It is commonly unexplained and often underdiagnosed cause of chronic pelvic pain in women of productive age. Pelvic venous pathologies are a part of multidisciplinary problem that should be considered in a holistic approach. Newly offered SVP classification may help correctly classifying patients and using the same nomenclature. Endovascular treatment options are highly effective with good long-term results. Patients with inconclusive gynecologists examinations should be referred to a specialist for the investigation of pelvic venous disorders.
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Affiliation(s)
- Suat Doganci
- Health Sciences University, Gulhane School of Medicine, Department of Cardiovascular Surgery Ankara/Turkey
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20
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Bartl T, Wolf F, Dadak C. Pelvic congestion syndrome (PCS) as a pathology of postmenopausal women: a case report with literature review. BMC WOMENS HEALTH 2021; 21:181. [PMID: 33906668 PMCID: PMC8077810 DOI: 10.1186/s12905-021-01323-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Abstract
Background Due to the scarcity of adequately powered, randomized controlled trials and internationally standardized diagnostic criteria, evidence on the diagnosis and treatment of pelvic congestion syndrome (PCS) is limited. Earlier epidemiologic observations led to the attribution of PCS to the premenopausal state, and a remission of symptoms after menopause is frequently described a hallmark of the pathology. This concept has currently been challenged by radiological studies reporting a notable prevalence of ovarian venous congestion in adult female patients of advanced age. PCS as a pathology of postmenopausal women, however, has not been acknowledged by systematic research to date, impeding appropriate diagnostics and therapy for affected patients. Case presentation A 69-year-old postmenopausal patient presented with newly diagnosed dilated and insufficient pelvic veins in combination with characteristic pain anamnesis, thereby fulfilling the diagnostic criteria of PCS. Interventional coil embolization of both ovarian veins as a standard treatment previously described for premenopausal patients was successfully performed, resulting in prompt alleviation of symptoms. The patient remained symptom-free at the 18-month follow-up visit. Conclusions Given this first systematically documented case of a patient with postmenopausal symptomatic PCS in the light of recently published data on the prevalence of ovarian venous congestion in patients of advanced age, it may be assumed that PCS is not to be considered a pathology strictly limited to premenopausal state. Further clinical studies expanding the diagnostic scope beyond menopause may help to substantiate evidence and subsequently define standardized therapeutic approaches for affected postmenopausal patients.
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Affiliation(s)
- Thomas Bartl
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Florian Wolf
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Dadak
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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21
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Abstract
The term pelvic venous disorders (PeVD) describes a group of related clinical entities with overlapping clinical presentations that were previously characterized by separate imprecise syndromic terminology. The clinical manifestations of PeVD may variously include chronic pelvic pain; pelvic origin extrapelvic lower extremity and genital varices; lower extremity pain and swelling; and left flank pain and hematuria. This manuscript focuses on the primary manifestations of PeVD in women - chronic pelvic pain and pelvic origin lower extremity and vulvar varices - and will review the underlying pathophysiology and related complicating factors (such as maladaptive pain responses) to explain the variety of clinical presentations.
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22
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Comment on Pelvic Venous Disorders in Women due to Pelvic Varices: Treatment by Embolization: Experience in 520 Patients. J Vasc Interv Radiol 2021; 32:763-764. [PMID: 33678568 DOI: 10.1016/j.jvir.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 11/22/2022] Open
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Gavrilov SG, Karalkin AV, Moskalenko YP, Grishenkova AS. Efficacy of two micronized purified flavonoid fraction dosing regimens in the pelvic venous pain relief. INT ANGIOL 2021; 40:180-186. [PMID: 33634687 DOI: 10.23736/s0392-9590.21.04579-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The venoactive drug treatment regimen for pelvic venous disorders (PeVDs) is not finally established. The study aimed at assessing the efficacy of micronized purified flavonoid fraction (MPFF) in a standard or double dose in the pelvic venous pain (PVP) relief in PeVD. METHODS We analyzed the treatment efficacy in 125 female patients with PeVD, who were allocated to two groups with MPFF treatment in a regular dose of 1000 mg once daily (OD) for 2 months (N.=65; group 1) or double dose of 1000 mg twice daily for 1 month and then 1000 mg OD for 1 month (N.=60; group 2). Patients underwent clinical examination along with an assessment of the PVP severity using the visual analogue scale (VAS) ranged from 0 to 10 scores, transvaginal and transabdominal duplex ultrasound scanning (DUS), and single-photon emission computed tomography (SPECT) of the pelvic veins with in vivo-labelled red blood cells (RBCs). The groups were different at baseline in the PVP severity (3.4±1.2 vs. 7.3±0.5 scores in groups 1 and 2, accordingly; P=0.012). DUS and SPECT were used to evaluate diameters of gonadal, parametrial, and uterine veins, to assess the presence of reflux in them, to measure blood flow velocity in the internal iliac veins (V<inf>lin IIV</inf>), and to calculate the coefficient of pelvic venous congestion (C<inf>PVC</inf>). RESULTS The treatment was associated with a significant reduction in the PVP score from 3.4±1.2 to 1.2±0.2 (P=0.03) when using the standard dose for 2 months and from 7.3±0.5 to 0.8±0.1 (P=0.001) when using the double dose in the 1st month. The PVP relief was achieved on average after 13.7±0.6 and 3.1±0.8 days in groups 1 and 2, accordingly (P=0.0001 between the groups). At month 2, the C<inf>PVC</inf> reduction was found to be significantly greater in group 2 compared to group 1 (46.6% vs. 25%; P=0.018). Side effects (gastralgia, flatulence) were reported by only 2 (3.3%) patients of group 2. CONCLUSIONS The venoactive drug therapy with MPFF is an effective and safe option for the PVP relief in female patients with PeVD. The use of double dose in the 1st month seems to be appropriate in patients with greater PVP severity but is associated with an increased rate of side effects.
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Affiliation(s)
- Sergey G Gavrilov
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia -
| | - Anatoly V Karalkin
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Yekaterina P Moskalenko
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anastasiya S Grishenkova
- Savelyev University Surgical Clinic, Pirogov Russian National Research Medical University, Moscow, Russia
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Awad AS, Taha MMM, Manaf MHA, Gad MMM, Mashhour SN. Role of multi-detector CT venography in evaluation of pelvic congestion syndrome. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00280-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pelvic congestion syndrome (PCS) is a problematic cause of chronic pelvic pain in women. It is thought to result from venous insufficiency of either ovarian or pelvic veins. Patients also present a variety of symptoms including dysuria and dyspareunia as well as vulva and buttock varicosities. The aim of this study is to evaluate the efficacy of multi-detector CT (MDCT) in diagnosis of PCS. Two hundred patients were included in our study and underwent CT venography of the abdomen and pelvis.
Results
We performed a prospective comparative study conducted on 200 patients. Thirty patients (15%) were diagnosed as PCS. There were congestion of the ovarian venous plexus and uterine venous engorgement in all patients. Filling of the veins across the midline was noted in 10 patients and filling of the vulval and thigh varicosities was noted in 3 patients. Ten patients had right ovarian vein dilatation; 12 patients had left ovarian vein dilatation; while 8 patients had bilateral ovarian vein dilatation. The right ovarian vein mean diameter (± SD) = 7.1 ± 0.8 mm; while the left ovarian vein mean diameter (± SD) = 7.6 ± 1 mm. Left ovarian venous reflux was found in 6 cases while no pathological reflux depicted on right side.
Conclusions
CT venography is considered as one of the initial investigations for the diagnosis of PCS in female patients with chronic pelvic pain making the further assessment by ovarian venography is for interventional management of diagnosed cases.
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Gavrilov SG, Vasilyev AV, Krasavin GV, Moskalenko YP, Mishakina NY. Endovascular interventions in the treatment of pelvic congestion syndrome caused by May-Thurner syndrome. J Vasc Surg Venous Lymphat Disord 2020; 8:1049-1057. [DOI: 10.1016/j.jvsv.2020.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/08/2020] [Indexed: 11/17/2022]
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Yu JH, Fang HH, Liu SY, Chang WC, Liu CC, Lin CM. Dual effects of a gonadotropin-releasing hormone agonist on an adolescent girl with pelvic congestion syndrome and precocious puberty: a case report. J Int Med Res 2020; 48:300060520954694. [PMID: 32967508 PMCID: PMC7521058 DOI: 10.1177/0300060520954694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Pelvic congestion syndrome (PCS) typically causes chronic non-cyclical abdominal pain with a considerable negative effect on the quality of life of women. However, pediatric cases with PCS are limited and non-invasive therapy for adolescent patients has not been reported. We report here a 13-year-old girl who presented with intermittent abdominal pain since the age of 2 years and her symptoms further deteriorated after breast development at 6 years and 9 months old. PCS and coexistent idiopathic central precocious puberty were finally diagnosed on the basis of tortuous ovarian and pelvic veins, and a pubertal response to a gonadotropin-releasing hormone (GnRH) test without hypothalamic–pituitary lesions. After treatment with the GnRH agonist, the pain score was greatly reduced and there was increased prediction of adult height. This case highlights the occurrence of PCS in adolescents and also indicates the role of non-invasive GnRH agonists in young patients with PCS before surgical intervention.
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Affiliation(s)
- Jwo-Huey Yu
- Department of Surgery, Taipei Veterans General Hospital, Taipei
| | - Hung-Hsiang Fang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Shih-Yao Liu
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chiung-Chen Liu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chien-Ming Lin
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei
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Knuttinen MG, Zurcher KS, Khurana N, Patel I, Foxx-Orenstein A, Harris LA, Lawrence A, Aguilar F, Sichlau M, Smith BH, Smith SJ. Imaging findings of pelvic venous insufficiency in patients with postural orthostatic tachycardia syndrome. Phlebology 2020; 36:32-37. [PMID: 32757696 DOI: 10.1177/0268355520947610] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Some patients with postural orthostatic tachycardia syndrome (POTS) demonstrate improved dysautonomic symptoms following treatment for pelvic venous insufficiency (PVI). This study assessed the prevalence of significant left common iliac vein (LCIV) compression in POTS patients. METHODS Radiologists retrospectively reviewed CT images of pelvic veins for 216 women (191 with POTS and 25 age-comparable controls).Quantitative vascular analysis identified percent-diameter compression of the LCIV by the right common iliac artery. Significant LCIV compression was defined as >50%. RESULTS Significant LCIV compression was found in 69% (131/191) of females with POTS versus 40% (10/25) in controls. The hypothesis that venous compression and presence of POTS are independent was rejected (p = .005). CONCLUSIONS Significant LCIV compression was noted in a majority of female POTS patients, suggesting that incidence of iliac venous obstruction may be higher than the general population. Patients with POTS and symptoms of PVI may benefit from assessment for venous outflow obstruction.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - B Holly Smith
- Center for the Advanced Study of Human Paleobiology, George Washington University, Washington, DC, USA
| | - Steven J Smith
- Vascular and Interventional Professionals, LLC., Hinsdale, IL, USA
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Jambon E, Le Bras Y, Petitpierre F, Balian E, Midy D, Grenier N, Marcelin C. MRI associated factors of clinical efficacy of embolization in patients with pelvic venous insufficiency. Diagn Interv Imaging 2020; 101:667-676. [PMID: 32713758 DOI: 10.1016/j.diii.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to identify anatomical findings at magnetic resonance imaging (MRI) associated with successful percutaneous embolization in women with pelvic venous insufficiency (PVI). MATERIAL AND METHODS Between 2008 and 2018, 168 consecutive women (mean age, 39±9 [SD] years; range: 21-69 years) who underwent percutaneous embolization for PVI confirmed by MRI and phlebography were included. Clinical efficacy of embolization was evaluated by patients' opinion or visual analogue scale. Associated factors of success of embolization were searched by comparing MRI findings in women with successful embolization with those in women with failed embolization using univariate analyses. RESULTS The mean follow-up was 36±29 (SD) months (range: 12-138 months). Clinical efficacy of embolization was obtained in 126/168 women (75%), complete symptom improvement in 33/168 women (20%) and significant partial improvement in 92/168 women (55%). No symptom improvement and symptoms exacerbation were observed in 17/168 (10%) and 2/168 (1%) women, respectively. At univariate analysis, right ovarian vein diameter≤7mm and vulvar varicosities were associated with successful embolization (P=0.04 and P=0.01, respectively) and left ovarian vein diameter≤7mm was associated with a complete improvement of symptoms (P=0.03). At multivariate analysis, a small right ovarian vein diameter was the single MRI variable associated with clinical efficacy of embolization (P=0.04). CONCLUSION Small ovarian vein diameters on MRI are associated with best clinical efficacy of percutaneous embolization in PVI. Right ovarian vein diameter>7mm should warrant further phlebography to exclude venous insufficiency.
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Affiliation(s)
- E Jambon
- Department of Radiology, Pellegrin Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - Y Le Bras
- Department of Radiology, Pellegrin Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - F Petitpierre
- Department of Radiology, Pellegrin Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - E Balian
- Departement of Functional Vascular Explorations, Tondu Hospital, 151, rue du Tondu, 33000 Bordeaux, France
| | - D Midy
- Department of Vascular Surgery, Pellegrin Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - N Grenier
- Department of Radiology, Pellegrin Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - C Marcelin
- Department of Radiology, Pellegrin Hospital, Place Amélie Raba Léon, 33076 Bordeaux, France.
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Aldhafery BF. What family physicians should know about interventional radiology? J Family Community Med 2020; 27:85-90. [PMID: 32831552 PMCID: PMC7415269 DOI: 10.4103/jfcm.jfcm_290_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/23/2020] [Accepted: 04/10/2020] [Indexed: 11/13/2022] Open
Abstract
Interventional radiology (IR) is a rapidly evolving specialty. The minimally invasive nature of the procedures has led to a paradigm shift in treating many disease processes from conventional surgery to interventional techniques that have become the first choice and the preferred method for the treatment of peripheral vascular disease, many aortic pathologies, and venous diseases. Interventional oncology procedures have become widely available for the treatment of solid hepatic and renal tumors. This includes palliative techniques for many advanced malignancies, and fluid drainage that is exclusively performed by interventional radiologists in many hospitals all around the world. Women's health-related procedures such as uterine fibroid embolization, fallopian tube recanalization, and embolization for pelvic congestion syndrome have become attractive choices for many patients. Family physicians (FPs) are the main source of patient referral to hospitals. However, there is a notable knowledge deficiency of IR among FPs in Saudi Arabia. This may be due to poor communication between FP and IR or the lack of FP's awareness of IR procedures. This is a nonsystematic review to introduce some IR procedures to FPs pertinent to their practice to optimize patient referral and management with the use of IR services. We focused on the most commonly performed IR procedures paying special attention to their clinical indications, benefits, and alternatives.
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Affiliation(s)
- Bander F Aldhafery
- Department of Radiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Comprehensive review of pelvic congestion syndrome: causes, symptoms, treatment options. Curr Opin Obstet Gynecol 2020; 32:237-242. [DOI: 10.1097/gco.0000000000000637] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Evaluation of goserelin effectiveness based on assessment of inflammatory cytokines and symptoms in uterine leiomyoma. Int J Clin Pharm 2020; 42:931-937. [PMID: 32350747 DOI: 10.1007/s11096-020-01030-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
Background Uterine leiomyoma is a benign tumour of the uterine smooth muscles associated with an elevated level of inflammatory cytokines. Goserelin, a synthetic gonadotropin-releasing hormone analogue, suppresses the production of sex hormones and release of inflammatory cytokines in uterine leiomyoma cells. Objective The primary objective of this study was to find out the effectiveness of subcutaneous goserelin therapy on lowering serum levels of inflammatory cytokines and improving uterine leiomyoma-related symptoms in female patients diagnosed with uterine leiomyoma. The secondary objective was to assess the tolerability to goserelin therapy used in the management of this tumour. Setting Outpatient gynaecological clinic of the medical consultation department of Baghdad Teaching Hospital, Baghdad province, Iraq. Methods A single centre, prospective, longitudinal, cohort study was carried out on female patients diagnosed with uterine leiomyoma. Goserelin 3.6 mg subcutaneous injection was given in a consecutive monthly dose for the total time duration of three months. Serum levels of inflammatory cytokines, tumour necrosis factor-α and monocyte chemotactic protein-1 were detected before and after goserelin therapy in a consecutive monthly assessment. The study also assessed the improvement in uterine leiomyoma-related symptoms, including pelvic pain alongside the incidence of goserelin-related side effects during therapy schedules. Main Outcome Measures Assessment of serum levels of tumour necrosis factor-α and monocyte chemotactic protein-1 alongside uterine leiomyoma-related symptoms, including pelvic pain and goserelin-related side effects. Results There was a significant decrease in serum levels of tumour necrosis factor-α and monocyte chemotactic protein-1 compared to the baseline level over the 3-month duration of goserelin therapy (0.11 ± 0.02 vs. 0.74 ± 0.19) pg/mL; (0.07 ± 0.00 vs. 0.44 ± 0.18) pg/mL respectively. Patients showed a clinical improvement regarding uterine leiomyoma-related symptoms following each of the consecutive monthly doses of goserelin therapy (n = 11, 55%, P < 0.0001; n = 15, 75%, P < 0.0001; n = 18, 90%, P < 0.0001) respectively. This also includes a significant decrease in the intensity of leiomyoma-related pelvic pain before and after goserelin therapy (7.2 ± 1.43 vs. 3.05 ± 1.14, P < 0.0001). The majority of patients reported vaginal dryness (60%) as the main goserelin-related side effect. Conclusion Goserelin therapy reduces serum levels of inflammatory cytokines, tumour necrosis factor- α and monocyte chemotactic protein-1, improving leiomyoma-related symptoms with good tolerability in patients with uterine leiomyoma.
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Hasjim BJ, Fujitani RM, Kuo IJ, Donayre CE, Maithel S, Sheehan B, Kabutey NK. Unique Case of Recurrent Pelvic Congestion Syndrome Treated with Median Sacral Vein Embolization. Ann Vasc Surg 2020; 68:569.e1-569.e7. [PMID: 32283303 DOI: 10.1016/j.avsg.2020.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/28/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pelvic congestion syndrome (PCS) is defined as noncyclical pelvic pain or discomfort caused by dilated parauterine, paraovarian, and vaginal veins. PCS is typically characterized by ovarian venous incompetence that may be due to pelvic venous valvular insufficiency, hormonal factors, or mechanical venous obstruction. METHODS We describe a case of a 38-year-old multiparous female with a history of pelvic pressure, vulvar varices, and dyspareunia. She underwent left gonadal vein coil embolization in 2014 for PCS that lead to symptomatic relief of her pain. Four years later, the patient returned for recurrent symptoms. Magnetic resonance venogram demonstrated dilated pelvic varices. The previously embolized left gonadal vein remained thrombosed, and there was no evidence of right gonadal vein insufficiency. However, catheter-based venography revealed a large, dilated, and incompetent median sacral vein. RESULTS Pelvic venography demonstrated left gonadal vein embolization without any evidence of reflux. The right gonadal vein was also nondilated without reflux. Internal iliac venography showed large cross-pelvic collaterals and retrograde flow via a large, dilated median sacral vein. Coil embolization of the median sacral vein resulted in a dramatic reduction of pelvic venous reflux and resolution of symptoms. CONCLUSIONS Recurrence of PCS can occur after ovarian vein embolization through other tributaries in the venous network. The median sacral vein is a rare cause of PCS. We present an interesting case of a successfully treated recurrent PCS with coil embolization of an incompetent median sacral vein.
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Affiliation(s)
- Bima J Hasjim
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA
| | - Roy M Fujitani
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA
| | - Isabella J Kuo
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA
| | - Carlos E Donayre
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA
| | - Shelley Maithel
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA
| | - Brian Sheehan
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA
| | - Nii-Kabu Kabutey
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, CA.
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Pelvic congestion syndrome: updated literature review. ANGIOLOGIA 2020. [DOI: 10.20960/angiologia.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Gibson K, Minjarez R. Vascular Disease Patient Information Page: Pelvic venous reflux (pelvic congestion syndrome). Vasc Med 2019; 24:467-471. [PMID: 31441390 DOI: 10.1177/1358863x19868282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Antignani PL, Lazarashvili Z, Monedero JL, Ezpeleta SZ, Whiteley MS, Khilnani NM, Meissner MH, Wittens CH, Kurstjens RL, Belova L, Bokuchava M, Elkashishi WT, Jeanneret-Gris C, Geroulakos G, Gianesini S, de Graaf R, Krzanowski M, Al Tarazi L, Tessari L, Wikkeling M. Diagnosis and treatment of pelvic congestion syndrome: UIP consensus document. INT ANGIOL 2019; 38:265-283. [PMID: 31345010 DOI: 10.23736/s0392-9590.19.04237-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | | | - Javier L Monedero
- Unity of Vascular Pathology, Ruber Internacional Hospital, Madrid, Spain
| | - Santiago Z Ezpeleta
- Unity of Radiology for Vascular Diseases, Ruber Internacional Hospital, Madrid, Spain
| | | | - Neil M Khilnani
- Division of Interventional Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mark H Meissner
- University of Washington School of Medicine, Seattle, WA, USA
| | - Cees H Wittens
- Department of Venous Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ralph L Kurstjens
- Department of Obstetrics and Gynecology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Ludmila Belova
- Faculty of Medicine, Ulyanovsk State University, Ulyanovsk, Russia
| | - Mamuka Bokuchava
- Tbilisi State Medical University, N. Bokhua Memorial Cardiovascular Center, Tbilisi, Georgia
| | | | - Christina Jeanneret-Gris
- Department of Angiology, University Clinic of Internal Medicine, KSBL Bruderholz, Baselland, Switzerland
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, Athens, Greece
| | | | - Rick de Graaf
- Clinic for Diagnostic and Interventional Radiology/Nuclear Medicine, Clinical Center of Friedrichshafen, Friedrichshafen, Germany
| | | | - Louay Al Tarazi
- Varicose Veins and Vascular Polyclinic (VVVC), Damascus, Syria
| | - Lorenzo Tessari
- Bassi-Tessari Foundation, Veins&Lymphatics Association ONLUS, Varese, Italy
| | - Marald Wikkeling
- Department of Vascular Surgery Heelkunde Friesland, Location MCL and Nij Smellinghe Hospital, Drachten, the Netherlands
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Jurga-Karwacka A, Karwacki GM, Schoetzau A, Zech CJ, Heinzelmann-Schwarz V, Schwab FD. A forgotten disease: Pelvic congestion syndrome as a cause of chronic lower abdominal pain. PLoS One 2019; 14:e0213834. [PMID: 30939134 PMCID: PMC6445463 DOI: 10.1371/journal.pone.0213834] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 03/03/2019] [Indexed: 02/04/2023] Open
Abstract
Objectives Pelvic congestion syndrome is defined as chronic pelvic pain due to incompetent (dilated and refluxing) pelvic veins. The aim of this study was to investigate the prevalence of this condition by examining the prevalence of dilated ovarian and para-uterine veins in pre- and postmenopausal female patients, irrespective of their symptoms. We subsequently investigated how many women with dilated veins suffered from chronic pelvic pain. Additionally, we attempted to define diagnostic criteria that may allow for early identification of affected patients. Methods We reassessed 2384 abdomino-pelvic computed tomography scans performed on women at our institution. The maximal diameters of the ovarian and para-uterine veins were measured. Patients with a pathological process in the abdomen or pelvis affecting the veins were excluded. We considered ovarian vein dilation to be 6 mm or more in the axial plane. For patients that met these criteria, we performed a retrospective chart review to evaluate the clinical presentation and/or symptoms of these patients. Results Dilated pelvic veins were present in 293/2384 (12%) patients, 118/559 premenopausal (21%) and 175/1825 postmenopausal (10%). Chronic pelvic pain of unclear etiology had been documented prior to the CT in 54/293 (18%) women with dilated veins—2% of the whole study collective (54/2384); 8% of all premenopausal (44/559) and 0.5% of all postmenopausal (10/1825). It was often accompanied by urological symptoms such as hematuria, dysuria, and urinary frequency, in the absence of infection (p<0.05). We identified a strong correlation between the presence of dilated ovarian veins and chronic pelvic pain in premenopausal parous patients with hematuria. Conclusions Pelvic congestion syndrome appears to be an underdiagnosed and undertreated disease. In our study, 8% of all premenopausal women had documented chronic pelvic pain of unclear etiology and dilated ovarian and pelvic veins on cross-sectional imaging studies. The features we identified in this study as most relevant should enable a faster identification of patients who could benefit from a specific treatment regimen for this condition.
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Affiliation(s)
- Agnieszka Jurga-Karwacka
- Department of Gynecology and Gynecological Oncology, University Women`s Hospital of Basel, University of Basel, Basel, Switzerland
| | - Grzegorz M. Karwacki
- Clinic of Radiology & Nuclear Medicine, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Andreas Schoetzau
- Ovarian Cancer Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Christoph J. Zech
- Clinic of Radiology & Nuclear Medicine, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Viola Heinzelmann-Schwarz
- Department of Gynecology and Gynecological Oncology, University Women`s Hospital of Basel, University of Basel, Basel, Switzerland
- Ovarian Cancer Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Fabienne D. Schwab
- Department of Gynecology and Gynecological Oncology, University Women`s Hospital of Basel, University of Basel, Basel, Switzerland
- * E-mail:
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Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2019; 8:3-17. [PMID: 30928249 DOI: 10.1016/j.sxmr.2018.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/08/2018] [Accepted: 12/10/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can coexist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia. AIMS To review the pathophysiology of deep dyspareunia, and to propose future research priorities. METHODS A narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)). MAIN OUTCOME VARIABLE Deep dyspareunia (present/absent or along a pain severity scale). RESULTS The narrative review demonstrates potential etiologies for deep dyspareunia, including gynecologic-, urologic-, gastrointestinal-, nervous system-, psychological-, and musculoskeletal system-related disorders. These etiologies can be classified according to anatomic mechanism, such as contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration. Etiologies of deep dyspareunia can also be stratified into 4 categories, as previously proposed for endometriosis specifically, to personalize management: type I (primarily gynecologic), type II (nongynecologic comorbid conditions), type III (central sensitization and genito-pelvic pain/penetration disorder), and type IV (mixed). We also identified gaps in the literature, such as lack of a validated patient-reported questionnaire or an objective measurement tool for deep dyspareunia and clinical trials not powered for sexual outcomes. CONCLUSION We propose the following research priorities for deep dyspareunia: deep dyspareunia measurement tools, inclusion of the population avoiding intercourse due to deep dyspareunia, nongynecologic conditions in the generation of deep dyspareunia, exploration of sociocultural factors, clinical trials with adequate power for deep dyspareunia outcomes, partner variables, female sexual response, pathways between psychological factors and deep dyspareunia, and personalized approaches to deep dyspareunia. Orr N, Wahl K, Joannou A, et al. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2020;8:3-17.
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Khilnani NM, Meissner MH, Learman LA, Gibson KD, Daniels JP, Winokur RS, Marvel RP, Machan L, Venbrux AC, Tu FF, Pabon-Ramos WM, Nedza SM, White SB, Rosenblatt M. Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2019; 30:781-789. [PMID: 30857986 DOI: 10.1016/j.jvir.2018.10.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Neil M Khilnani
- Division of Interventional Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 2315 Broadway, Fourth Floor, New York, New York 10128.
| | - Mark H Meissner
- Division of Vascular Surgery, University of Washington Medical Center, Seattle, Washington
| | - Lee A Learman
- Department of Obstetrics and Gynecology, Charles A. Schmidt School of Medicine, Florida Atlantic University, Boca Raton, Florida
| | | | - Jane P Daniels
- Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Ronald S Winokur
- Division of Interventional Radiology, New York Presbyterian Hospital, Weill Cornell Medical College, 2315 Broadway, Fourth Floor, New York, New York 10128
| | | | - Lindsay Machan
- Departments of Radiology and Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony C Venbrux
- Division of Interventional Radiology, George Washington University School of Medicine, Washington, DC
| | - Frank F Tu
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois; Department of Obstetrics and Gynecology, North Shore University Medical Group, Skokie, Illinois
| | - Waly M Pabon-Ramos
- Division of Interventional Radiology, Duke University School of Medicine, Durham, North Carolina
| | - Susan M Nedza
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sarah B White
- Division of Interventional Radiology, Froedtert Hopsital, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mel Rosenblatt
- Connecticut Image-Guided Surgery, Fairfield, Connecticut
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Brown CL, Rizer M, Alexander R, Sharpe EE, Rochon PJ. Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin Intervent Radiol 2018; 35:35-40. [PMID: 29628614 DOI: 10.1055/s-0038-1636519] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pelvic venous insufficiency is now a well-characterized etiology of pelvic congestion syndrome (PCS). The prevalence of CPP is 15% in females aged 18 to 50 years in the United States and up to 43.4% worldwide. In addition to individual physical, emotional, and quality-of-life implications of CPP, there are profound healthcare and socioeconomic expenses with estimated annual direct and indirect costs in the United States in excess of 39 billion dollars. PCS consists of clinical symptoms with concomitant anatomic and physiologic abnormalities originating in venous insufficiency. The etiology of PCS is diverse involving both mechanical and hormonal factors contributing to venous dilatation (>5 mm) and insufficiency. Factors affecting the diagnosis of PCS include variance of causes and clinical presentations of pelvic pain and relatively low sensitivity of noninvasive diagnostic imaging and laparoscopy to identify insufficiency compared with catheter venogram. A systematic review of the literature evaluating patient outcomes following percutaneous treatment of PCS is presented.
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Affiliation(s)
- Candace L Brown
- Diagnostic and Interventional Radiology, Advanced Radiology Services, Grand Rapids, Michigan
| | - Magda Rizer
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ryan Alexander
- Department of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emerson E Sharpe
- Department of Interventional Radiology, Kaiser Permanente, Denver, Colorado
| | - Paul J Rochon
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE. Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 2018; 97:776-786. [PMID: 29381188 PMCID: PMC6033028 DOI: 10.1111/aogs.13311] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/22/2018] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Miranda P Steenbeek
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Leo J Schultze Kool
- Department of Radiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Theodoor E Nieboer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
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Rodríguez-Nora B, Álvarez-Silvares E. [An update on the treatment of venous insufficiency in pregnancy]. Semergen 2017; 44:262-269. [PMID: 29249567 DOI: 10.1016/j.semerg.2017.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/16/2017] [Accepted: 11/03/2017] [Indexed: 11/18/2022]
Abstract
Chronic venous insufficiency is a long-term pathological condition resulting from anatomical or functional alterations of the venous system. This leads to the appearance of symptoms and physical signs that affect a large part of the population and particularly pregnant women, due to the physiology of pregnancy. The few published studies on the use of pharmacological treatments of venous insufficiency in this group of the population, often makes the management of this condition difficult in routine clinical practice. A review is presented in this article, with all the latest updates in the treatment of this condition during pregnancy. There are numerous general, and some pharmacological, recommendations, that we can safely offer the pregnant patient.
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Affiliation(s)
- B Rodríguez-Nora
- Medicina de Familia y Comunitaria, Complexo Hospitalario Universitario de Ourense, Ourense, España
| | - E Álvarez-Silvares
- Servicio de Obstetricia y Ginecología, Complexo Hospitalario Universitario de Ourense, Ourense, España.
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Abstract
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.
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Affiliation(s)
| | - Vivak Hansrani
- Department of Vascular Surgery, University Hospital of South Manchester, Manchester, UK
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A Modern Radiologic Treatment for Pelvic Congestion Syndrome Associated with Chronic Pelvic Pain and Menstrual Abnormalities. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/jeppd.5000301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction With greater than one-tenth of outpatient gynecology visits attributed to chronic pelvic pain, research into etiology and management of the spectra of chronic pain disorders is very important. One such etiology, pelvic congestion syndrome (PCS), is a disease in which pelvic varicosities are present as a result of dysfunctional venous valves, retrograde blood flow, venous hypertension, and dilation. The presence of these varicosities, which exist in up to 10% of women between 18 and 76 years of age, can be detected by various imaging techniques including ultrasound, contrasted computed tomography, and magnetic resonance imaging. Various treatment methodologies have been described for the management of this chronic pain disorder, including medical, endovascular, and surgical therapies. With advancements in imaging, and the opportunity for endovascular intervention via interventional radiology, minimally invasive left ovarian vein embolization is at the forefront of therapeutic efforts for this nefarious condition. Methods We present here our clinical experience of 9 patients with PCS who underwent left ovarian vein embolization using a standardized protocol. Results Subjective pain relief was noted in 8 of 9 patients; 7 of the 9 patients reported complete resolution of pain at the 4-week follow-up, and associated symptoms similarly resolved. Conclusions Any thorough evaluation of a patient with chronic pelvic pain should include an evaluation for PCS when the diagnosis is not immediately available. Increased physician awareness of PCS is imperative for the future. With these astounding results, we recommend an excellent option for treatment of patients with left ovarian vein embolization.
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Abstract
INTRODUCTION This brief review describes conservative treatment methods for pelvic venous congestion. Therapy options: The authors present an analysis of the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), ergot alkaloid derivatives, hormonal agents, venoprotective agents, and compression therapy in the treatment of pelvic congestion syndrome (PCS) as well as indications for medical therapy. CONCLUSION The paucity of studies addressing this topic and the need for large multidisciplinary studies to explore the opportunities for non-surgical treatment of PCS are highlighted.
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Affiliation(s)
- S G Gavrilov
- a Faculty of Surgery and Urology , Therapeutic Faculty of the N.I. Pirogov Russian National Research Medical University , Moscow , Russia
| | - O O Turischeva
- a Faculty of Surgery and Urology , Therapeutic Faculty of the N.I. Pirogov Russian National Research Medical University , Moscow , Russia
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Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess 2016; 20:1-108. [PMID: 26789334 DOI: 10.3310/hta20050] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Rita Champaneria
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laila Shah
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jonathan Moss
- Department of Radiology, North Glasgow University Hospitals, Glasgow, UK
| | - Janesh K Gupta
- Institute of Metabolism and Systems Biology, University of Birmingham, Birmingham, UK
| | | | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jane P Daniels
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Siedentopf F, Weijenborg P, Engman M, Maier B, Cagnacci A, Mimoun S, Wenger A, Kentenich H. ISPOG European Consensus Statement - chronic pelvic pain in women (short version). J Psychosom Obstet Gynaecol 2016; 36:161-70. [PMID: 26514847 DOI: 10.3109/0167482x.2015.1103732] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To date there is no international guideline on chronic pelvic pain available that focuses on medical, psychosomatic and psychological diagnostics and treatment of this complicated disease pattern. In this paper, a European working group, which was established in October 2010, aims to bridge this gap. The working group decided to use the current German guideline as source text and to transform it into a European consensus statement by deleting parts that apply only to the conditions of the German health system. The literature search included papers published up to and including December 2010, using Medline search and by adding some new search terms. This manuscript reports the essential facts of the above-mentioned consensus statement. Within this article we use the term "psychosomatic" as the integrated concept of medical and psychosocial aspects of a disease.
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Affiliation(s)
- Friederike Siedentopf
- a Department of Gynecology and Obstetrics , Martin-Luther-Hospital , Berlin , Germany
| | | | | | - Barbara Maier
- d Department of Gynaecology & Obstetrics , Hanusch-Hospital of the Vienna District Health Insurance Funds (WGKK) , Vienna , Austria
| | - Angelo Cagnacci
- e Department of Medical and Surgical Sciences of the Mother , Child and Infant, Institute of Obstetrics and Gynaecology , Modena , Italy
| | - Sylvain Mimoun
- f Cabinet privé, Department of Gynecology and Obstetrics , Paris , France
| | - Anna Wenger
- g UK Salzburg , Psychosomatik , Salzburg , Austria , and
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The Prevalence of Ovarian Varices in Patients with Endometriosis. Ann Vasc Surg 2016; 34:135-43. [DOI: 10.1016/j.avsg.2015.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/08/2015] [Accepted: 12/10/2015] [Indexed: 11/18/2022]
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Meissner MH, Gibson K. Clinical outcome after treatment of pelvic congestion syndrome: sense and nonsense. Phlebology 2016; 30:73-80. [PMID: 25729071 DOI: 10.1177/0268355514568067] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic pelvic pain accounts for approximately 10% of outpatient gynecologic visits and among the varied causes, pelvic congestion syndrome is second only to endometriosis in frequency. Manifestations may include pelvic pain, dyspareunia, dysuria, and dysmenorrhea as well as external varices and a number of psychosocial symptoms. Although a variety of treatments have been proposed-including pharmacologic ovarian suppression, hysterectomy with or without oophorectomy, and ovarian vein resection-transcatheter embolization is the least invasive and most efficacious management option. Complete or partial symptom improvement has been reported in 68.2-100% of patients and there has been a consistent reduction in visual analog pain scores after treatment. Based upon these results, recommendation of either pharmacotherapy or other surgical procedures is difficult to justify. However, it is also clear that 6-31.8% of patients do not get substantial relief from pelvic venous embolization. Potential explanations for an inadequate response to treatment include patient variability, procedural variability, and inadequate outcome measures. The latter are particularly important and future investigation should focus on the development of disease-specific quality of life measures as well as identifying those aspects of the procedure, such as choice of embolic agents and extent of embolization, associated with the best clinical outcomes.
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Affiliation(s)
- M H Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, USA
| | - K Gibson
- Lake Washington Vascular Surgeons, Bellevue, USA
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50
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Abstract
Peripheral generators and the central nervous system have a role in the production of visceral and somatic hypersensivities and hyperalgesias.More generalised symptoms often exist and efferent activity from the CNS may also be responsible for abnormal visceral and muscular function.It is important to dissect out the symptoms and as well as treating peripheral generators to consider interventions of the central mechanisms aimed at the cognitive behavioural aspects of the patients' condition.
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