Ultrasound Technology & Innovation

Key Indicators of Pelvic Congestion Syndrome on Ultrasound

Pelvic congestion syndrome (PCS) is an underdiagnosed cause of pelvic pain that can be detected through a combination of ultasound and physical exams.

Pelvic congestion syndrome (PCS) can be hard to detect and is often overlooked. While enlarged veins are a telltale sign, this condition's primary — and often only — symptom is pain. Pelvic pain is one of the most common complaints that drives patients to a gynecologist, but PCS still remains largely underdiagnosed.

Through a combination of physical examination and ultrasound imaging, physicians can accurately distinguish PCS from other conditions when a patient presents with pelvic pain.

What Is Pelvic Congestion Syndrome?

Up to 30 percent of women with chronic pelvic pain may have PCS, according to a study published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. In PCS, chronic pelvic pain is triggered by reflux or obstruction of the veins around the uterus. These veins become enlarged, similar to varicose veins.

Premenopausal women who have had at least two children tend to be the most likely group to experience this condition, possibly because pregnancy causes veins to enlarge. Not all women with enlarged pelvic veins experience pain, but pain is the deciding factor used when making a PCS diagnosis. Chronic pelvic pain, lasting at least six months and typically focused on the left side, is the primary presenting symptom. A patient's pain may worsen before or during menstruation, or after sitting or standing all day. This condition can also cause stress incontinence to worsen.

How to Diagnose Pelvic Congestion Syndrome

PCS is diagnosed partly through a physical exam, during which a clinician looks for the presence of varicose veins in the thighs, vulva or buttocks, and partly through ultrasound imaging.

Abdominal and transvaginal ultrasound can detect the presence of enlarged veins. The ovarian vein is the most common culprit of PCS, but the internal iliac vein, internal pudendal veins, the obturator veins and the ischial vein can also become enlarged and cause pain.

On ultrasound, an ovarian vein measuring greater than 6 mm in diameter points to a diagnosis of PCS, according to a study published in Seminars in Interventional Radiology. Color Doppler ultrasound can also help identify varicose veins in the pelvis. PCS appears as reversed venous flow, particularly during the Valsalva maneuver.

Nutcracker syndrome is a related condition that often causes PCS. It is present when the left renal vein between the aorta and the superior mesenteric artery is compressed. Besides the pelvic pain common in PCS, patients with nutcracker syndrome may also present with hematuria.

PCS is sometimes a diagnosis of exclusion as well. With the presence of enlarged veins and the absence of symptoms of other conditions that may cause pelvic pain, treatment for PCS may be recommended.

Treatment of Pelvic Congestion Syndrome

For women nearing menopause, a conservative approach may be appropriate for managing PCS. Estrogen is thought to cause or worsen the condition; as estrogen decreases during menopause, the pain may abate on its own. Another noninvasive treatment option is progestin, which helps reduce pain by shrinking the size of the veins.

Minimally invasive treatment with percutaneous transcatheter pelvic vein embolization (PVE) to block off the enlarged vein is most often the preferred method when progestin is not effective. Surgery to remove the damaged veins may be needed in rare cases. In women with nutcracker syndrome and PCS, endovascular stenting of the left renal vein may alleviate symptoms, but as this treatment option is relatively new, research on its effects is scarce. 

PCS is a fairly common cause of pelvic pain, but it remains underdiagnosed. Careful ultrasound evaluation to detect dilated veins and to rule out other causes of pain is essential in developing an accurate treatment plan.