How is pelvic congestion syndrome recognized?

For years I have suffered from pelvic pain, bloating, intestinal disorders and urinary tract infections. I consulted several specialists and underwent laparoscopic surgery, but nothing was found in the gynecological field. After years of suffering they removed part of my intestine, but I continue to have pain that forces me to take medications and seriously limits my daily activities, at home and at work. I have had three pregnancies and was recently diagnosed with a pelvic varicocele: what can I do?

He replies Domenico Baccellieridirector Vein Center, San Raffaele Hospital, Milan (GO TO THE FORUM)

We are used to correlating venous pathology with varicose veins of the lower limbs, very widespread and visible manifestations in the population, but circulatory failure of the veins can also be localized in the abdomen and particularly in the pelvis. Female varicocele is characterized by the formation of venous dilations in the lower parts of the abdomen and portal blood stagnation with possible pain, perineal heaviness, urinary urgency and pain during and after sexual intercourse. Pelvic congestion syndrome can have multiple triggers and different types of symptoms, but is always related to increased blood volume in the pelvis and the state of inflammation of all the organs contained therein. It is estimated that approximately 15% of the population may have reflux of the ovarian veins secondary to the congenital lack of valve systems, but in most cases the problem represented by Acquired conditions often worsened by the number of pregnancies.

The lack of progression of blood towards the heart can be generated by dilation of the veins or malfunctionconditions that cause pelvic reflux, or situations that prevent effective venous return such as obstructive syndromes (May Thurner syndrome and Nutcracker syndrome). The diagnosis is very complex and must always be based on multidisciplinary consultations that can exclude the numerous causes of pelvic pain of a neurological, gynecological, gastroenterological and urological nature. It is enough to mention endometriosis, a very widespread and severely disabling pathological condition, or problems of the gastrointestinal tract such as the common irritable bowel syndrome. The test of choice for the diagnosis of pelvic congestion transvaginal ultrasound with color Doppler, through which it is possible to evaluate the pelvic venous plexus in dimensional and functional terms, obtaining precise information on the localization of the dilations. In the second instance it is necessary to carry out a radiological study with magnetic resonance angiography which will add important information on the anatomy of the venous vessels, course, essential dimensions, to plan a possible treatment.

Technological evolution now allows pelvic congestion syndrome to be treated with minimally invasive methods aimed at closing pathological vessels. The operation takes place under local anesthesia often with access from a vein in the arm, through endovascular navigation the deficient venous vessels are reached and treated using embolization, i.e. occlusion with spirals and sclerosing foam. In the case of obstructive syndromes such as MayThurner's syndrome (severe compression or obstruction of the left common iliac vein which causes venous hypertension in the left limb and inversion of flow in the pelvic district with severe stagnation), it may be necessary endovascular placement of a stent which restores the correct direction of circulation to the heart. It is important to contact high-volume centers with a multidisciplinary approach, to prevent the chronic nature of the pain from causing it to be irreversible.

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