Pelvic Venous Insufficiency

Pelvic venous insufficiency (PVI) refers to backward flow in the pelvic veins due to incompetent valves. PVI plays a role in the development of Pelvic Congestion Syndrome (PCS), and pelvic varices. Though one can have PCS without the presence of varices, this article focuses on PCS in conjunction with pelvic varies, during or after pregnancy.

Pelvic Congestion Syndrome (PCS)

Pelvic congestion syndrome is defined as chronic pelvic pain, persisting longer than six months, due to retrograde flow (reflux) in an incompetent ovarian vein[1]. It is estimated that one third of women will have PCS at some point in their lifetime. Along with pelvic pain, PCS may present with the following symptoms or indications:

  • Pelvic Heaviness
  • Pelvic Varices
  • Leg Varicosities
  • Ovarian Tenderness
  • Dyspareunia (pain during sex)
  • Dysmenorrhea (cramping pain during menstruation)

There are multiple compression syndromes such as Nutcracker syndrome and May Thurner’s Syndrome, which can contribute to PCS, but this article focuses on pregnancy as a cause.

Pregnancy as a cause of PCS & Varices

During pregnancy, flow to the reproductive system increases by up to 60x the normal amount[2]. To accommodate the increase in flow, pelvic veins, mainly the ovarian and internal iliac veins, dilate. In a normal system, valves in the veins close to prevent backward flow; however, during pregnancy vein dilation prevents the valve leaflets from closing completely, and backward flow is allowed through the veins. This dysfunction is termed pelvic reflux or insufficiency. This insufficiency of the pelvic veins to return blood to the heart from the pelvis can result in PCS, and pelvic varices.

Pelvic Varices

Varicose veins are superficial veins that are swollen and dilated, and appear like a twisted chord close to the surface of the skin. Varicose veins with a pelvic source are typically visualized on physical examination in three areas:

  • Vulvar varices: these varices are found in the vulva
  • Perineal varices: varices within the perineum, which is the space between the vagina and anus
  • Gluteal varices: these varices are seen in the buttock and posterior thigh region

Varices from these three areas often continue down into the legs, and present with similar symptoms as varicose veins that originate in the legs, such as pain and swelling of the ankle and calf, or leg heaviness/achiness at the end of the day.

Diagnostic tests for PCS

The gold standard, or most accurate method to test for PCS and pelvic varices is conventional venography (CV). Duplex ultrasound (DU), magnetic resonance venography (MRV), and computed tomography venography (CTV) are other technologies that may be utilized; however, of the existing methods, duplex ultrasound is the only one that is non-invasive, and with no radiation exposure.

Treatment Options

Treatment for pelvic venous insufficiency can vary depending on which vein requires treatment. If the varices themselves are treated directly, typically phlebectomy or sclerotherapy is performed. Treatment of an incompetent ovarian vein or internal iliac vein requires the use of foam sclerotherapy, or coil embolization. The process for these procedures and questions regarding them should be explained in full by one’s doctor.

[1] The Journal for Vascular Ultrasound 40(1):14-19, 2016 “A study comparing the results of duplex ultrasound and magnetic resonance venography to diagnostic pelvic vein congestion”

[2]Meissner MD, Mark.  “Pelvic Venous Insufficiency” Oral presentation at UC Davis Medical Center Vascular Laboratory Conference, 2016.