Pelvic Congestion Syndrome (PCS)
Pelvic Congestion Syndrome (PCS) is a complex medical condition caused by dilated internal varicose veins within the lower abdomen and pelvis, which unlike varicose veins of the leg, cannot be seen on the surface of the body. Sadly, this condition is misdiagnosed or goes unrecognized in women’s clinics because there are many different causes of chronic pelvic pain, which is defined by a duration of longer than six months and is not related to the menstrual cycle. 30% of women with chronic lower abdominal or pelvic pain in fact suffer from PCS, which can be disabling and affect relationships and their quality of life.
Women who suffer from PCS typically experience:
- Deep pelvic or uterine pain (described as a “dull ache” or “dragging sensation”).
- The pain usually worsens during the day and is made worse by prolonged standing or exercise and relieved by lying down.
- Pain can be sharp when there is a change in posture, during walking or lifting heavy items or in any activity that increases the pressure in the pelvic area.
- Women suffering from pelvic congestion syndrome symptoms can experience painful menstruation, which may lead to a misdiagnosis as endometriosis by gynaecologists.
- Discomfort during or after sexual intercourse
- Associated pain on urination (dysuria), urge incontinence and an increased need to urinate during the night.
- Irritable bowel symptoms include recurrent abdominal pain, and diarrhoea alternating with periods of constipation.
One of the commonest pelvic congestion syndrome symptoms is the presence of dilated twisted veins around the front passage (vagina and vulval varicose veins), inner thigh and buttock regions. Many women who develop these varicose veins around these regions, especially after pregnancy are told by their maternity nurses and obstetricians that these veins cannot be removed or cured, which is incorrect and can be readily dealt with by minimally invasive procedures under local anaesthetic or sedation.
The cause of pelvic congestion syndrome remains unclear, but the possibility of anatomical abnormalities or hormonal imbalance can contribute to its development. The majority of women who are affected by PCS are in the 20-45 years age range. PCS can affect not only women who have never been pregnant but also worsen in those who have had numerous pregnancies.
One theory is that hormonal changes and weight gain along with anatomical changes in the pelvis during pregnancy can cause an increase in pressure in the ovarian and pelvic veins. This leads to weakening in the vein wall leading to dilatation and disruption of the valve function of the normal veins, which would normally allow blood to flow from the pelvis to the heart preventing backflow and congestion otherwise known as venous reflux.
PCS can be diagnosed readily in expert hands by taking a careful history and performing a transvaginal ultrasound scan, which will look for dilated veins in the pelvis. Sometimes a computed tomography (CT) or magnetic resonance imaging (MRI) study is required to visualize the abnormal varicose veins in the pelvis more closely and to look for other abnormalities within the same region.
Pelvic venography: This is currently the most definitive imaging modality for diagnosing PCS. It is a minimally invasive procedure performed potentially as a day case in a hospital by a vascular specialist/surgeon under local anaesthetic or sedation. A special thin tube called a catheter is positioned from the groin or neck vein under x-ray guidance into the dysfunctional ovarian or pelvic veins, and images are obtained using an iodine-based dye injected via the catheter into the target vein. Pelvic venography can be used in conjunction with pelvic ovarian embolization (see below) to definitively treat PCS.