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

Abstract

BackgroundPelvic 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.ObjectivesOur 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 sourcesA 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.MethodsMethodological 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.ResultsWe 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.ConclusionsThe 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 registrationThis study is registered as PROSPERO CRD42012002237 and CRD42012002238.FundingThe National Institute for Health Research Health Technology Assessment programme.

A Current View on the Problem of Varicose Veins of the Pelvis (Review)

“…One of the common VVP symptoms, which is paid no attention to by the physicians or not associated with this pathology, is atypical varicosity, expressed by varicose veins of perineum, vulva, inner thigh and buttock area. Once these altered veins are detected, their connection with each other, the great saphenous vein, and its branches must be compulsorily revealed as isolated pelvic varicose veins are found in 35-40% of women, in other 60-65% of cases the disease usually occurs in the combination with varicose veins of low extremities [46][47][48][49][50][51].…”

“…not more than 5 mm [14,40,74], and the average diameter of the arcuate veins is 1.1±0.4 mm [74]. Veins with the diameter exceeding 5 mm are considered dilated [22,51,67,68].…”

“…They are located along the anterior abdominal wall and abdominal rectus muscle slightly lateral to the iliac veins and arteries [78]. The diameter over 5 mm and presence of retrograde blood flow are considered the sign of ovarian vein incompetence at USAS [2,51,69]. USAS of the veins of low extremities, perineum, vulva, inner femoral surface, and buttocks area is mandatory for the adequate examination, prevention of recurrences, and correct treatment tactics.…”

Ovarian Vein Embolization with N-butyl-2 Cyanoacrylate Glubran-2® for the Treatment of Chronic Pelvic Pain Secondary to Pelvic Congestion Syndrome

“…Despite an increasing awareness of this condition, the precise etiology of CPP secondary to PCS remains uncertain, which is probably related to multifactor. Pelvic vein incompetence with retrograde ow in varicose utero-ovarian plexus, has been implicated as one of the most important causes in CPP secondary to PCS [4].…”

Calcitonin Gene-Related Peptide and Substance P As Predictors of Venous Pelvic Pain

“…Chronic pelvic pain (CPP) is a highly relevant and challenging problem of modern medicine [1,2]. According to the World Health Organization (WHO), the prevalence of CPP ranges from 2.4 to 24% of the population, with women of reproductive age being the most predominant group affected [5].…”