Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome)

A Case Study of Successful Application of the Principles of ME/CFS Care to an Individual with Long COVID

Persistent fatigue is one of the most common symptoms of post-COVID conditions, also termed long COVID. At the extreme end of the severity spectrum, some individuals with long COVID also meet the criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), raising the possibility that symptom management approaches for ME/CFS may benefit some long COVID patients. We describe the long-term outcomes of a 19-year-old male who developed profound impairment consistent with ME/CFS after a SARS-CoV-2 infection early in the pandemic. We evaluated and treated him using our clinic’s approach to ME/CFS. This included a history and physical examination that ascertained joint hypermobility, pathological reflexes, physical therapy maneuvers to look for a range of motion restrictions in the limbs and spine, orthostatic testing, and screening laboratory studies. He was found to have profound postural tachycardia syndrome, several ranges of motion restrictions, and mast cell activation syndrome. He was treated according to our clinic’s guidelines for managing ME/CFS, which included manual physical therapy maneuvers and both non-pharmacologic measures and medications directed at postural tachycardia syndrome and mast cell activation. He experienced significant improvement in his symptoms over 30 months. His case emphasizes how the application of the principles of treating ME/CFS has the potential to provide a direction for treating long COVID.

World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound

Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex disease that affects children and adolescents as well as adults. The etiology has not been established. While many pediatricians and other health-care providers are aware of ME/CFS, they often lack essential knowledge that is necessary for diagnosis and treatment. Many young patients experience symptoms for years before receiving a diagnosis. This primer, written by the International Writing Group for Pediatric ME/CFS, provides information necessary to understand, diagnose, and manage the symptoms of ME/CFS in children and adolescents. ME/CFS is characterized by overwhelming fatigue with a substantial loss of physical and mental stamina. Cardinal features are malaise and a worsening of symptoms following minimal physical or mental exertion. These post-exertional symptoms can persist for hours, days, or weeks and are not relieved by rest or sleep. Other symptoms include cognitive problems, unrefreshing or disturbed sleep, generalized or localized pain, lightheadedness, and additional symptoms in multiple organ systems. While some young patients can attend school, on a full or part-time basis, many others are wheelchair dependent, housebound, or bedbound. Prevalence estimates for pediatric ME/CFS vary from 0.1 to 0.5%. Because there is no diagnostic test for ME/CFS, diagnosis is purely clinical, based on the history and the exclusion of other fatiguing illnesses by physical examination and medical testing. Co-existing medical conditions including orthostatic intolerance (OI) are common. Successful management is based on determining the optimum balance of rest and activity to help prevent post-exertional symptom worsening. Medications are helpful to treat pain, insomnia, OI and other symptoms. The published literature on ME/CFS and specifically that describing the diagnosis and management of pediatric ME/CFS is very limited. Where published studies are lacking, recommendations are based on the clinical observations and practices of the authors.

Isolated large vulvar varicose veins in a non-pregnant woman

Vulvar varicosities are often asymptomatic, and they may be associated with varicose veins of the lower extremity. Also, they may be a part of pelvic congestion syndrome and usually occur during pregnancy. We present a case of a huge isolated and disfiguring vulvar varicosities in a non-pregnant women managed successfully by combination of surgery and sclerotherapy.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

Role of trans vaginal ultrasound and Doppler in diagnosis of pelvic congestion syndrome

Pelvic congestion syndrome (PCS) is a cause of chronic pelvic pain in women and is defined as pelvic pain lasting for more than six months.The diagnosis of PCS is a challenging task for the gynaecologist. It can be due to many varied causes like endometriosis, adhesions, chronic pelvic inflammatory disease (PID), ovarian cyst, fibroids, pelvic varicosities. Radiology plays an important role in the diagnosis and management of PCS. Pelvic UltraSonography (PUS),transvaginal sonography (TVS) with doppler, Magnetic resonance imaging (MRI), computed tomography (CT) and ovarian venography are usually used in the diagnosis of this condition. We report a case of a 35-year-old multiparous patient with history of pain in lower abdomen, vaginal discharge and general lethargy for past three years who was diagnosed as a case of PCS based on typical TVS and Doppler findings.

Embolization to treat pelvic congestion syndrome and vulval varicose veins

OBJECTIVE

To evaluate the efficacy of embolization for treating the symptoms of pelvic congestion syndrome (PCS).

METHODS

Twenty-one women with PCS who were treated with embolization at Radboud University Nijmegen Medical Centre between 2003 and 2008 were sent a questionnaire about their symptoms before embolization, 2 months after the first embolization, and at the time the survey was conducted.

RESULTS

All patients completed the questionnaire. Two months after the first embolization, 14 (66.7%) women had some degree of improvement of symptoms. Nine (42.9%) patients underwent a second embolization. At the time the survey was conducted, 16 (76.2%) patients had some degree of improvement of symptoms. In addition to improvements in varicose veins and pelvic pain, there was improvement of hemorrhoids.

CONCLUSION

Embolization of pelvic varicosities may be an effective treatment in a well-selected group of patients with PCS. If there is no improvement of symptoms after initial embolization, a second procedure is unlikely to be effective.

Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings

There are various causes of varicose veins in the lower extremities. Among the causes are venous insufficiency of the saphenofemoral junction, saphenopopliteal junction, or usual perforating veins. Traditionally, Doppler ultrasonography (US) has been used for evaluation of varicose veins. Sometimes, varicose veins arise from an unexpected anatomic source; in these cases, computed tomographic (CT) venography can provide an overview of the varicose veins. Doppler US with complementary CT venography is useful for determining the precise cause of varicose veins. Between November 2003 and March 2008, the authors evaluated 1350 cases of varicose veins in the lower extremities with both CT venography and Doppler US. The varicose veins were classified according to their causes; unusual causes were studied and included vulvoperineal varicosity, intraosseous perforating vein incompetence, round ligament varicosity, persistent sciatic vein incompetence, Klippel-Trenaunay syndrome, and portosystemic collateral pathways. Radiologists should be familiar with the complete range of primary causes of varicose veins in the lower extremities and with their radiologic manifestations and should recognize the complementary role of CT venography in their evaluation.

Pelvic congestion syndrome: diagnosis and treatment

The diagnosis of pelvic congestion syndrome (PCS) continues to challenge all physicians involved especially those in such specialties as anesthesia, gastroenterology, general surgery, obstetrics and gynecology, and interventional radiology. When other pelvic pathology is ruled out, an interventional radiologist may be consulted for additional evaluation and treatment of PCS. A heightened awareness and clinical suspicion for the specific symptomatology and associated findings may bring about a more rapid progression toward treatment. For most interventional radiologists who treat PCS patients, magnetic resonance imaging/MR venography (MRI/MRV), diagnostic venogram, and embolotherapy are at the center of diagnosis and treatment of PCS.

Chronic pelvic pain in women of childbearing age

PURPOSE OF REVIEW

The purpose of this article is to summarize new findings in the area of chronic pelvic pain in women of childbearing age.

RECENT FINDINGS

Particular attention over the past few years has been paid to the multidisciplinary approach in diagnosing and treating chronic pelvic pain, because it is common knowledge that different medical specialties very often deal with patients affected by this condition.

SUMMARY

A classification of chronic pelvic pain is presented, along with the recommended evaluation, diagnostic investigations, and treatment of this condition, based on recent reports in the literature.

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

STUDY OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

Twenty-three women.

INTERVENTION

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Adolescent pelvic pain

Chronic pelvic pain is a frequent complaint in adolescent females. It is a complex disorder with multiple causes. The assessment must attempt to differentiate between gynaecological and non-gynaecological sources of pain. An understanding of the physical, cognitive and environmental factors associated with the pain are essential. Laparoscopy has been used in the assessment of CPP but a significant number of patients will have no obvious aetiology at the time of laparoscopy. For the young patient with CPP, a multidisciplinary approach may be essential to facilitate diagnosis and management. Although the symptoms may not always be curable, management that allows the young female to obtain normal or near normal function may be possible. This chapter focuses on the various causes of pelvic pain in the adolescent female with a focus on the assessment, diagnosis and treatment of the different causes.

Ovarian veins: magnetic resonance imaging findings in an asymptomatic population

PURPOSE

To evaluate the magnetic resonance (MR) venographic appearance of the ovarian veins in a healthy population, correlated with surgical findings. Our data can be used as a basis for comparison to patients with suspected pelvic congestion syndrome (PCS).

MATERIALS AND METHODS

We retrospectively reviewed exams of 22 women who had MR angiography for potential renal donation evaluation (age range, 19.3-60.5 years; mean, 38 years). We evaluated the diameter of the ovarian veins on dynamic multiphasic postcontrast coronal images, the phase of contrast appearance in these veins, the apparent direction of flow, and the presence of ovarian or pelvic varices. Surgical correlation was obtained in 12 patients. Clinical charts were reviewed and patients were asked about symptoms of chronic pelvic pain and the number of their children.

RESULTS

Of the 22 exams, 21 left gonadal veins were identified. Passive reflux from the left renal vein into the left gonadal vein was suggested in eight exams (38%). These veins had a mean diameter of 6.4 +/- 1.6 mm, significantly larger than 4.5 +/- 1.3 mm for the other 13 left gonadal veins without reflux (P < 0.005). The right gonadal vein was identified in 8 of 22 women, with a mean diameter of 4.4 +/- 0.5 mm. No patient reported symptoms of chronic pelvic pain.

CONCLUSION

Passive reflux from the left renal vein to the left gonadal vein can occur in asymptomatic women. Diagnosis of PCS depends heavily on appropriate clinical history.

Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain

PURPOSE

The purpose of this study was to analyze the impact of transcatheter embolotherapy on pain perception and menstrual cycle in women with chronic pelvic pain caused by the presence of ovarian and pelvic varices (ie, women with pelvic congestion syndrome or pelvic venous incompetence).

MATERIALS AND METHODS

From July 1998 to August 2000, 56 patients (mean age, 32.3 y) were treated for chronic pelvic pain. Diagnostic venography of the ovarian veins was followed by transcatheter embolotherapy with a sclerosing agent and coils. A second session was completed to embolize the internal iliac veins in 43 of 56 patients. Visual analog scales (VAS) used to measure pain were administered before embolization and at 3-, 6-, and 12-month follow-up. Questionnaires regarding menstrual history were used as part of the postprocedural analysis.

RESULTS

Percutaneous transcatheter embolotherapy of ovarian and pelvic varices was technically successful in 56 of 56 patients (100%); three patients developed recurrent varices, two of whom were treated with repeat transcatheter embolotherapy. Two patients, early in the experience, had complications in which coils placed in the internal iliac veins embolized to the pulmonary circulation; the coils were snared without clinical sequelae. On the VAS, the mean baseline pain level was 7.8 (range, 3.2-9.8; n = 56); at 3-month follow-up, it was 4.2 (range, 0.0-7.2; n = 56); at 6 months, 3.8 (range, 0.0-6.7; n = 41); and at 12 months, 2.7 (range, 0.0-6.9; n = 32). Differences were significant (P <.001) between baseline pain levels and those at all follow-up intervals (ie, 3, 6, and 12 months). The mean decrease in VAS was 5.1 (65% decrease). The clinical follow-up in this series ranged between 6 and 38 months; the mean was 22.1 months. Regarding the impact of embolization on menstruation, all 24 patients responding to questionnaires indicated no change in menstrual cycle.

CONCLUSION

For patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS without any notable impact on menstrual cycle.

A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion

Following identification of the proportion of pelvic congestion among symptomatic patients complaining of chronic pelvic pain, and in a totally asymptomatic group of patients requesting tubal ligation, the efficiency of goserelin acetate versus medroxyprogesterone acetate was compared objectively using pelvic venogram scores, and subjectively by symptom resolution, improvement of psychological status and sexual functioning in a prospective randomized trial in 47 patients with pure pelvic congestion syndrome. Patients received either goserelin acetate (3.6 mg/month for 6 months) or medroxyprogesterone acetate (MPA; 30 mg/day for 6 months). Among patients with chronic pelvic pain, those with pure pelvic congestion were mostly parous, had the most severe pelvic signs and symptom scores, lowest rates of sexual functioning, and higher states of anxiety and depression as compared with others. At 1 year after treatment, goserelin remained superior to MPA in terms of pelvic venographic improvement as an objective measure. In alleviation of signs and symptomatology, improvement of sexual functioning and reduction of anxiety and depressive states as subjective measures, goserelin acetate achieved a statistically significant advantage (P = 0.0001) compared with MPA.

Transvaginal ultrasound examination of women with and without pelvic venous congestion

AIM

To determine if transvaginal ultrasound, including power Doppler examination, can distinguish between women with and without pelvic congestion.

MATERIALS AND METHODS

Thirty-six women with pelvic congestion were prospectively examined using transvaginal ultrasonography and standard uterine and ovarian measurements made. Additionally, planimetric measurements of each ovary were taken using an image analysis program to determine the cross-sectional area of ovarian stroma and follicles, if any. Power Doppler images of adnexal vessels were obtained and planimetric estimates of surface area calculated. A congestion score was assigned to each patient, based on vein number, diameter and morphology on grey-scale scanning. Identical measurements were obtained from 19 asymptomatic women and results compared.

RESULTS

There was no significant difference between women with pelvic congestion and controls with respect to power Doppler or grey-scale images of adnexal vessels, or congestion score. However, women with pelvic congestion had significantly larger and multicystic ovaries when compared to controls.

CONCLUSIONS

Transvaginal ultrasound measurements of adnexal vasculature, including power Doppler measurements, cannot reliably distinguish women with pelvic congestion from controls. However, ultrasound may remain useful for diagnosis of pelvic congestion, predominantly because it is able to visualize multi-cystic ovaries in these patients.