Chronic pelvic pain is potentially debilitating and affects millions of women worldwide with a reported incidence of up to 39%. Routine evaluation yields no obvious etiology for chronic pelvic pain in up to one-third of cases. In cases in whom there is no identifiable cause of pelvic pain, an estimated 30% may actually have pelvic venous congestion (PVC)—also known as pelvic venous insufficiency (PVI) or pelvic congestion syndrome (PCS). Unfortunately, PVC is still often overlooked in the differential diagnosis of chronic pelvic pain.

Affected patients are generally multiparous and typically present in their late 20s or early 30s with a history of chronic pelvic pain of greater than 6 months’ duration. The classic and almost pathognomonic presentation includes varying degrees of positional pelvic and lower back pain that is exacerbated by prolonged standing and strenuous activity. Other symptoms include the following.

The combination of postcoital ache and ovarian point tenderness is reported to be 94% sensitive and 77% specific for the diagnosis of PVC when confirmed by venography. Patients may present with atypical nonsaphenous pudendal, vulvar, and perilabial varicosities which are visible on physical examination and ultrasound (US). Incompetent pelvic varices also often collateralize into posterolateral thigh and gluteal regions. An increased incidence of symptomatic PVC has been reported in patients suffering from complex nonsaphenous patterns of lower extremity superficial venous insufficiency.

The discomfort of PVC is due to venous distension of ovarian and pelvic varicosities. It is associated with uterine enlargement, thickened endometrium, and cystic changes in the ovaries. The etiology of PVC is multifactorial, and includes factors such
as primary gonadal valvular insufficiency, hormonally mediated vasomotor dysfunction, and venous outflow obstruction. Central venous outflow obstruction can occur with a retroaortic left renal vein or compression of the left renal vein by the superior mesenteric artery (Nutcracker syndrome). Compression of the left common iliac vein by the right iliac artery (May–Thurner syndrome) can also cause symptomatic pelvic collaterals off of the left internal iliac vein with similar clinical presentation. Multiple approaches to the management of symptomatic PVC have been described, including hormonal suppression, hysterectomy, with or without oophorectomy, and transcatheter embolization. In appropriate patients, transcatheter embolization is now considered the gold standard for treatment of PVC.

The list of differential diagnoses for chronic pelvic pain is extensive and it is imperative that other pelvic pathology be excluded as part of the work-up for PVC. Although laparoscopy, US, computed tomography (CT), and magnetic resonance imaging (MRI) can demonstrate pelvic varices, the primary goal and utility of laparoscopy and noninvasive imaging in the work-up of PVC is to exclude concurrent nonvascular pelvic pathology. These modalities are limited by low sensitivity for the detection of primary gonadal and PVI. There is limited published data comparing laparoscopy, US, CT, and MRI to the generally accepted gold standard of catheter-directed venography. In a longer-term, 2-year study of 131 patients with a confirmed diagnosis of PCS, the sensitivities of laparoscopy, MRI, US, and CT were found to be 40%, 58.6%, 20%, and 12.5%, respectively. The investigators found no difference in clinical outcomes from embolization for PVC between those patients who had positive pre-embolization cross-sectional imaging or those patients who had directly visualized pelvic varices by laparoscopy compared to those with negative laparoscopy and negative noninvasive imaging. The authors attributed this observation to relatively low sensitivities for laparoscopy, MRI, US, and CT. It is estimated that over 80% of pelvic varices go undetected by laparoscopy due to technical limitations which include compression of the varices from peritoneal CO₂ insufflation and the resultant decompression of varices while the patient is in Trendelenburg position.