US Imaging of pelvic congestion syndrome

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1 US Imaging of pelvic congestion syndrome Poster No.: C-1210 Congress: ECR 2015 Type: Educational Exhibit Authors: D. S. Baviskar, S. Baviskar; Abu Dhabi/AE Keywords: Pelvis, Vascular, Veins / Vena cava, Ultrasound, UltrasoundColour Doppler, Ultrasound-Power Doppler, Diagnostic procedure, Education and training, Varices DOI: /ecr2015/C-1210 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 13

2 Learning objectives The aim of this presentation is to highlight the clinical presentation, diagnosis and imaging features, especially related to Ultrasonography of Pelvic Congestion Syndrome. Background Evaluation of vague lower abdominal / pelvic pain in women is a challenge to all physicians. One of the causes of vague, chronic lower abdominal / pelvic pain in women is Pelvic Congestion Syndrome. The term "Pelvic Congestion Syndrome" was first introduced by Taylor. (1) Pelvic Congestion Syndrome is defined as a condition characterised by visible congestion of the pelvic veins on selective ovarian venography in multiparous, premenopausal women with a history of chronic pelvic pain for more than 6 months. (2) Pelvic congestion syndrome occurs when the valves of the ovarian veins become weak and do not close properly. This results in backflow and pooling of blood, causing bulging of veins and pain. It can affect uterus, ovaries or vulva. It has been seen that up to 15% of women between the ages of years have varicose veins in the pelvis, although not all are symptomatic. (4) Risk factors associated with pelvic congestion syndrome are multiparity, associated varices in legs, polycystic ovaries and hormonal dysfunction. Apart from chronic pelvic pain the patient usually complains of menorrhagia, dysmenorrhoea, dyspareunia, increased vaginal discharge, increased urinary frequency and constipation. Although there is no definite cause for Pelvic congestion syndrome, it is seen mostly in premenopausal and multiparous women suggesting the possibility of a hormonal aetiology.(5) The imaging modalities for diagnosis of Pelvic congestion syndrome are : Ultrasound - Trans abdominal & Trans vaginal Doppler CT Scan - Contrast enhanced CT Scan Page 2 of 13

3 Magnetic Resonance Imaging (MRI) Catheter Venography The treatment modalities for Pelvic congestion syndrome available are : Medical - Analgesics, HRT, Gonadotropins receptor agonists (GnRH), Medroxyprogesterone acetate (MPA), etc. Interventional - Transcatheter embolisation of the ovarian and pelvic veins Surgery - Laproscopic ligation of the ovarian veins, hysterectomy, bilateral salphingo-oophorectomy. Findings and procedure details The path towards a definitive diagnosis of Pelvic Congestion Syndrome has been long and painful for many women. When other pelvic pathologies have been ruled out, possibility of Pelvic congestion Syndrome needs to be excluded. According to SJ Park et al (3) The sonographic findings ( Fig. 1 on page 4, Fig. 2 on page 4, Fig. 3 on page 5, Fig. 4 on page 6 ) in pelvic congestion syndrome were: dilated left ovarian vein with reversed caudal flow presence of varicocele dilated arcuate veins crossing the uterine myometrium polycystic changes in the ovary variable duplex waveform during valsalva`s maneuver. The trans abdominal USG can be performed addtionally in standing position, wherever required. CT Scan will show varicosities throughout the lower pelvis. MRI / MR Venography is the best primary imaging modality in investigating Pelvic congestion Syndrome ( Fig. 5 on page 7, Fig. 6 on page 8, Fig. 7 on page 9, Fig. 8 on page 10, Fig. 9 on page 11 ), as it is non-invasive, has better soft tissue and vessel delineation and there is no ionising radiation. But, due to its cost factor and expertise required, it is has limited availability. Page 3 of 13

4 Catheter Venography provides physicians with relaible minimally invasive tool in patients with pelvic congestion syndrome.(6) Images for this section: Fig. 1: Transvaginal USG showing dilated veins in the right adnexa Page 4 of 13

5 Fig. 2: Transvaginal USG Doppler image showing dilated veins in the right adnexa Page 5 of 13

6 Fig. 3: Transvaginal USG Doppler showing dilated veins in the right adnexa. One of the veins measures 10 mm in diameter Page 6 of 13

7 Fig. 4: Transvaginal USG showing venous varix in the adnexa. Page 7 of 13

8 Fig. 5: MRI Pelvis. STIR Coronal image showing dilated veins in bilateral adnexa. Page 8 of 13

9 Fig. 6: MRI Pelvis. STIR Axial image showing dilated veins in bilateral adnexa. Page 9 of 13

10 Fig. 7: MRI Pelvis. SPC 3D Coronal image showing dilated veins in bilateral adnexa. Page 10 of 13

11 Fig. 8: MRI Pelvis. Post Contrast Axial image showing dilated veins in bilateral adnexa. Page 11 of 13

12 Fig. 9: MRI Pelvis. Post Contrast Coronal image showing dilated veins in bilateral adnexa. Page 12 of 13

13 Conclusion There has to be increased awareness and high clinical suspicion about Pelvic Congestion Syndrome, in women of child bearing age group, who present with complaints of vague lower abdominal / pelvic discomfort for a period of over 6 months. Since, correct diagnosis of pelvic congestion syndrome will aid in rapid treatment and recovery from the symptoms. Personal information References HC Taylor. Jr. Vascular congestion and hyperemia; their effect on function and structure in the female reproductive organs; the clinical aspects of the congestion-fibrosis syndrome. Am J Obstet Gynecol.1949;57(4): Beard R W, Pearce S, Highmanm JH, Reginald PW. Diagnosis of pelvic varicosities in women with chronic peliv pain. Lancet 1984;2: SJ Park, JW Lim, YT Ko, DH Lee, Y Yoon, JH Oh, et al. Diagnosis of pelvic congestion syndrome using trans abdominal and trans vaginal sonography. AJRAm J Roentgenol. 2004;182(3): AM Rozenblit, ZJ Ricci, J Tuvia, ES Amis. Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. Am J Roentgenol. 2001;176: RW Beard, PW Reginald, J Wadsworth. Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol. 1988;95(2): Stones RW, Pelvic vascular congestion-half a century later, Clin. Obster Gynecol 2003;46; Page 13 of 13

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