Pelvic congestion syndrome in female patients

Dr. Tobias Hirsch from Germany provided an overview of PCS, how to diagnose and treat it, and what the current guidelines are in that field.

Mark Whiteley

He demonstrates how to suspect the disease based on patient symptoms and the role of pelvic ultrasound with CT scan and Venogram that can confirm the condition, the symptoms include vulval varicosity, pelvic discomfort, and dyspareunia.

He explains that causes of pelvic congestion, such as ovarian vein reflux lift renal vein compression, also known as nutcracker syndrome, or left to common iliac vein compression maintenance, also known as May Turner syndrome, or lastly pelvic leak sites. 

Dr. Hirsch shows the multiple diagnostic tools that can help to confirm the case as duplex ultrasound or intravascular ultrasound or MRI venogram or CT venogram and shared the European Society of vascular surgery” ESVS” classification of pelvic congestions syndrome with different approach of treating pelvic congestion syndrome.

The requirement for a patient assessment for pelvic congestion syndrome is critical including the patient's medical history, psychological health, and utilization of self-assessment questionnaires.

According to Dr. Hirsch, a good evaluation routine can help set the patient's course of action and lead interventions, which may include vascular examination, imaging, or surgical procedures. For patients with varicose veins of pelvic origin who do not have pelvic symptoms, exclusion of other causes of pain and local procedures for varicose veins and pelvic escape points are recommended as the initial therapeutic approach, while pelvic vein embolization is recommended for those who do have pelvic symptoms. However, the guidelines do not cover all aspects of pelvic venous diseases.

Dr. Hirsch explains the several treatment options for people suffering from pelvic congestion syndrome, which may include interventional treatment, and surgical procedures such as ovarian vein ligation or renal vein transposition. Dr. Hirsch emphasizes the need for tailored treatment as well as the importance of considering any co-morbidities and symptoms such as discomfort and bloating. Furthermore, the speaker emphasizes the need of non-invasive treatments such as psychotherapy and Vino active medications and he describes a patient with chronic pelvic pain who was misdiagnosed before being diagnosed with pelvic venous problems.

Dr. Hirsch discusses several different cases of pelvic congestion syndrome and how they were diagnosed and treated. The first patient was a 22-year-old woman with no history of childbirth or typical risk factors but with varicose veins in her pelvis. he sent her for a venogram, which revealed a left ovarian vein insufficiency with a big caliber and a very early reflux filling. Rather than treating with a stand, they started with ovarian vein occlusion using coils or plugs and in combination with sclerotherapy.

The second patient had varicose veins but no pelvic pain symptoms, so he decided to do an ultrasound-guided sclerotherapy of the pelvic escape point first before therapy of the external varicose veins in the labia area and leg without the intervention of the gonadal veins for now. He also describes how they use foam and coils to occlude veins in the pelvis.

Dr. Hirsch discusses the proper treatment of pelvic venous disorders, such as using foam to flow into the network and needing a control one to two weeks later to ensure there are no remaining varicose veins. The lecture emphasizes the importance of proper patient assessment and communication, as well as the use of duplex ultrasound as a basic imaging tool for pelvic venous disorders. The Q&A session was very active with different questions on when to choose embolization, vein surgery, or minimal invasive for patients.

Dr. Hirsch emphasizes the importance of treating pelvic congestion syndrome (PCS) conservatively initially. The decision to use open surgery or intervention depends on the center chosen for treatment. The experts mentioned that the diagnosis of PCS is challenging, particularly in determining whether it is caused by reflux disease or obstructive disease. They talk about the limitations of laparoscopic surgery for deep-set internal iliac veins and the lack of head-to-head studies comparing the effectiveness of open surgery and intervention. While HIFU technology could be helpful in treating the exit points of pelvic leakages, the experts do not consider it useful for treating PCS in the short term.

Watch the full session

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