Servier – Phlebolymphology

Abstract

Pelvic congestion syndrome is an important cause of chronic pelvic pain that develops due to pelvic, but particularly ovarian, vein incompetence. Pelvic pain is one of the frequent reasons for outpatient gynecologic visits. Unfortunately, large and reliable studies on the prevalence of pelvic congestion syndrome do not yet exist; therefore, only indirect data, such as the prevalence of chronic pelvic pain, presence of atypical varicose veins, dyspareunia, etc, can be analyzed. Chronic pelvic pain is often amplified by physical activity and both during and after coitus, and it significantly worsens patients’ quality of life and reduces their social activity. A systematic approach and data from large population-based studies are needed to identify the real prevalence and accurately measure the quality of life in patients with pelvic congestion syndrome.

Introduction

In the mid-19th century, Richet observed an association between chronic pelvic pain and the presence of varicose veins in the utero-ovarian plexus; he also described the presence of pelvic varices.¹ In 1949, Taylor first described pelvic venous enlargement as a cause of chronic pelvic pain²; this was also shown in 1976 by Hobbs³ and 1985 by Lechter.⁴ In 1984, Beard et al defined pelvic congestion syndrome as a condition characterized by visible congestion of pelvic veins on selective ovarian venography in multiparous, premenopausal women with a history of chronic pelvic pain lasting longer than 6 months.⁵ In 2009, pelvic congestion syndrome was described in the VEIN-TERM transatlantic interdisciplinary consensus document as “chronic symptoms, which may include pelvic pain, perineal heaviness, urgency of micturition and postcoital pain, caused by ovarian and/or pelvic vein reflux and/or obstruction, and which may be associated with vulvar, perineal, and/or lower extremity varices.”⁶

Prevalence and costs

Pelvic congestion syndrome is an important cause of chronic pelvic pain in women due to pathological venous hemodynamics in ovarian and pelvic veins.

As many as 39% of women have reported experiencing pelvic pain at some time in their life.⁷ From 2% to 10% of all gynecological office consultations are for pelvic pain, and nearly 20% of all laparoscopic procedures are performed for chronic pelvic pain. It is estimated that 10 million women suffer from this condition, with approximately 7 million who do not seek treatment.

The economic impact of CPP is astonishing. The annual medical cost for diagnosis and treatment of CPP is estimated to be about $ 1.2 billion. The cost of lost productivity in these patients is estimated to be $ 15 billion annually.⁸

Up to 61% of patients have no explanation for their pain.⁸ The worldwide prevalence of chronic pelvic pain has been estimated to vary from 5.7% in Austria to 26.6% in Egypt.⁹ It is a common presentation in UK primary care, with 3.8% of women affected annually—a rate comparable with those of asthma (3.7%) and back pain (4.1%).¹⁰

Noncyclic chronic pelvic pain
According to the first systematic review of the worldwide prevalence of chronic pelvic pain (18 studies; 299 740 women), the prevalence rate of noncyclic pelvic pain ranged from 4.0% to 43.4%.¹¹ The 3-month prevalence of noncyclic pelvic pain was 15% in women between the ages of 18 and 50 in the USA and 24% in women between the ages of 12 and 70 in the UK.^12,13 The prevalence rates in developing countries in Southeast Asia varied from 5.2% in India and 8.8% in Pakistan to 43.2% in Thailand.¹⁴ Among the causes of chronic pelvic pain, pelvic congestion syndrome accounts for 16% to 31% of all cases, which is second only to endometriosis in prevalence.⁹

Pelvic pain without an apparent cause
In patients with no apparent causes of pelvic pain, ≈30% were shown to have pelvic venous insufficiency,¹⁵ and 10% had ovarian vein dilatation.¹⁶ Pelvic congestion syndrome may develop in up to 60% of women with ovarian vein dilatation.¹⁶ In a study by Soysal et al in 2001, women presenting with chronic pelvic pain were analyzed with a pelvic examination, laparoscopy, ultrasonography, and venography.¹⁷ Of the women screened, 31% had pelvic congestion syndrome as the only abnormality, and 12% had pelvic congestion syndrome plus another pelvic pathology, such as endometriosis, pelvic inflammatory disease, postoperative adhesions, and uterine disease (myoma or adenomyosis).¹⁷ In addition, the incidence increases with the number of pregnancies. This may explain the lower incidence in the USA as the number of pregnancies are lower (1 or 2), whereas, in other countries with higher numbers of pregnancies, the condition is extremely common.¹⁸

Pelvic varicosities
In 1976, Hobbs examined 1000 women in a vascular clinic and identified a 4% incidence of perivulvar varicosities.³ Venous clinics that have used pelvic venography or transvaginal or transperineal duplex sonography to evaluate all patients with pelvic pain, Doppler ultrasound evidence of lower limb venous insufficiency, and evidence of pelvic venous origin have shown that 15% to 20% of patients have lower limb varicosities with a partial or complete pelvic origin. However, the percentage of such patients can be as high as 30%.^19-21 Jiang et al reported that pelvic venous insufficiency was the source of nonsaphenofemoral reflux in the groin in 6.1% of patients with primary varicose veins.²² Garcia-Gimeno et al found that reflux from the pelvis or abdominal wall can also occur in 42% of patients with primary varicose veins associated with sapheno-femoral reflux and, in 35% of those, reflux in the anterior accessory great saphenous vein.^23,24

Depending on the length of the follow-up (5 to 20 years) and the definition of recurrence, between 20% and 80% of patients have recurrent varices after surgery (REVAS), which may result from the development of collateral veins between the pelvis and lower limbs.^25-28 No more than 45% of recurrences occur in the region of the great saphenous vein, suggesting that the cause of pelvic pain is due to reflux in the pelvic veins.^28,29

Not all women with atypical varicosities have pelvic pain, approximately one-third of those with pelvic congestion syndrome have vulvovaginal varices, and up to 90% may have lower limb varices. Conversely, approximately 5% of women presenting with lower extremity varicose veins will have concurrent pelvic symptoms. It is important to note that pelvic varicosities do not uniformly lead to disabling symptoms. Using CT or MRI examinations, ovarian varicosities have been identified in 38% to 47% of asymptomatic women.^9,30 Often, the real prevalence of pelvic congestion syndrome is unclear and large population-based studies are needed.

Quality of life

Pelvic congestion syndrome is usually diagnosed in women who are younger than 45 and reproductively active (ie, 1 to 2 children); however, evidence-based studies on the quality of life of patients with pelvic congestion syndrome have not been conducted, and special quality of life instruments have not been developed. Certain factors, such as pain, physical activity, family life, sexual relationship, and work and social life, determine the quality of life of patients with pelvic congestion syndrome.

For pelvic congestion syndrome, patients typically have noncyclic pelvic pain that is usually exacerbated during menstruation and after standing or sitting for long periods. In most cases, pain is assessed using a visual analog scale (VAS). The pretreatment range of pain intensity by VAS in different studies varies between 7.2 and 8.5 points.^9,17,28,31 These values are very high, showing that pelvic pain considerably influences quality of life in patients with pelvic congestion syndrome. The pain is usually localized to the pelvis, but may be present across the whole abdomen and in the lower back. The pain is usually described as a dull ache with intermittent acute exacerbation that is aggravated by physical activity, which primarily affects women’s ability to perform their usual daily activities. In addition, the complexity of correctly diagnosing the disease leads to numerous consultations with various specialists (eg, gynecologist, urologist, gastroenterologist, neurologist, and proctologist), and this time-consuming process negatively affects the psycho-emotional status of the patient.

Psychosomatic dysfunction is also inherent for pelvic congestion syndrome. Taylor wrote that “psychiatric disturbances, usually of an emotional character, are a common accompaniment of pelvic congestion.”² Pelvic congestion syndrome is often accompanied by depression (25% to 50%), anxiety (10% to 20%), and somatic complaints (10% to 20%).¹⁷ Dysmenorrhea, dysuria, and, in particular, dyspareunia are the major factors that influence the sexual relationship between partners. In patients with pelvic congestion syndrome, there is a reduction in the possibilities for both regular work–because sitting or standing for long periods exacerbates the pain–and an active social life.

The assessment of quality of life in patients with pelvic congestion syndrome is very difficult because no disease specific quality-of-life tools have been developed, and generic quality-of-life tools do not provide sufficient estimates of the quality of life.

Conclusion

Unfortunately, there are no systematic studies to globally understand the prevalence of pelvic congestion syndrome and evaluate the quality of life of these patients. However, data acquired by evaluating individual symptoms, as well as comparing these symptoms with similar syndromes, provide information to predict a high prevalence and poor quality of life. Nevertheless, we need a systematic approach and data from large population studies to identify the real prevalence and accurately measure quality of life in patients with pelvic congestion syndrome.

REFERENCES
1. Richet MA. Traité Pratique d’Anatomie Medico-Chirugicale. Paris: E. Chamerot Libraire Editeur; 1873
2. Taylor HC Jr. Vascular congestion and hyperemia; their effects on the structure and the function in the female reproductive system. Am J Obstet Gynecol. 1949;57:637-653.
3. Hobbs JT. The pelvic congestion syndrome. Practitioner. 1976;216:529- 540.
4. Lechter A. Pelvic varices: treatment. J Cardiovasc Surg. 1985;26:111.
5. Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 1984;2:946-949.
6. Eklof B, Perrin M, Delis K, Rutherford R, Gloviczki P. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49:498- 501.
7. Robinson JC. Chronic pelvic pain. Curr Opin Obstet Gynecol. 1993;5:740-743.
8. Perry CP. Current concept of pelvic congestion and chronic pelvic pain. JSLS. 2001;5:105-110.
9. Meissner MH, Gibson K. Clinical outcome after treatment of pelvic congestion syndrome: Sense and nonsense. Phlebology. 2015;30(suppl 1):73-80.
10. Daniels JP, Khan KS. Chronic pelvic pain in women. BMJ. 2010;341:c4834.
11. Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177.
12. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87:321-327.
13. Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Prevalence and incidence of chronic pelvic pain in primary care: Evidence from a national general practice database. Br J Obstet Gynaecol. 1999;106:1149-1155.
14. Thongkrajai P, Pengsaa P, Lulitanond V. An epidemiological survey of female reproductive health status: gynecological complaints and sexually-transmitted diseases. Southeast Asian J Trop Med Public Health. 1999;30:287-295.
15. Kim HS, Malhorta AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17:289-297.
16. Belenky A, Bartal G, Atar E, Cohen M, Bachar GN. Ovarian varices in healthy female kidney donors: incidence, morbidity, and clinical outcome. AJR Am J Roentgenol. 2002;179:625-627.
17. Soysal ME, Soysal S, Vicdan K, Ozer S. A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. Hum Reprod. 2001;16:931-939.
18. Gloviczki P, ed. Handbook of Venous Disorders. 3rd ed. London, UK: Edward Arnold Ltd; 2009.
19. Marsh P, Holdsock J, Harrison C, Smith C, Price BA, Whiteley MS. Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service District General Hospital. Phlebology. 2009;24(3):108-113.
20. Whiteley AM, Taylor DC, Whiteley MS. Pelvic venous reflux is a major contributory cause of recurrent varicose veins in more than a quarter of women. J Vasc Surg. 2013;1:100-101.
21. Holdstock JM, Dos Santos SJ, Harrison CC, Price BA, Whiteley MS. Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux. Phlebology. 2015;30:133-139.
22. Jiang P, van Rij AM, Christie RA, Hill GB, Thomson IA. Non-saphenofemoral venous refluxin the groin in patients with varicose veins. Eur J Vasc Endovasc Surg. 2001;21:550-557.
23. Garcia-Gimeno M, Rodriguez-Camarero S, TagarroVillalba S, et al. Duplex mapping of 2036 primary varicose veins. J Vasc Surg. 2009;49:681-689.
24. Hartung O. Embolization is essential in the treatment of leg varicosities due to pelvic venous insufficiency. Phlebology. 2015;30(suppl 1):81-85.
25. Perrin M, Guex JJ, Ruckley CV, et al. Recurrent varices after surgery (REVAS) a consensus document. Cardiovasc Surg. 2000;8:233-245.
26. Kostas T, Ioannou CV, Touloupakis E, et al. Recurrent varicose veins after surgery: a new appraisal of a common and complex problem in vascular surgery. Eur J Vasc Endovasc Surg. 2004;27:275-282.
27. Perrin MR, Labropoulos N, Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg. 2006;43:327-334.
28. Lopez AJ. Female pelvic vein embolization: indications, techniques, and outcomes. Cardiovasc Intervent Radiol. 2015;38:806-820.
29. Ndiaye A, Ndiaye A, Ndoye JM, et al. The arch of the great saphenous vein: anatomical bases for failures and recurrences after surgical treatment of varices in the pelvic limb. About 54 dissections. Surg Radiol Anat. 2006;28(1):18-24.
30. van der Vleuten CJ, van Kempen JA, Schultze-Kool LJ. Embolization to treat pelvic congestion syndrome and vulval varicose veins. Int J Gynaecol Obstet. 2012;118: 227-230.
31. Laborda A, Medrano J, de Blas I, Urtiaga I, Carnevale FC, de Gregorio MA. Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up evaluation in 202 patients. Cardiovasc Intervent Radiol. 2013;36:1006-1014.