Pelvic Congestion Syndrome Embolization

Background and indications

Pelvic congestion syndrome (PCS) is a common but underdiagnosed cause of chronic pelvic pain in women, accounting for up to 30% of chronic pelvic pain cases. It is caused by reflux and dilation of the ovarian and/or uterine veins (pelvic varicocele), similar to the mechanism of male varicocele. Risk factors include multiparity, venous anatomical abnormalities (Nutcracker syndrome, May-Thurner syndrome), and hormonal variations.

Typical symptoms include chronic non-cyclical pelvic pain worsened by prolonged standing and at the end of the day, pain during intercourse (dyspareunia), pelvic heaviness sensation, vulvar varicose veins, or atypical lower limb varicose veins. Embolization is the reference treatment after diagnostic confirmation, when medical treatment has failed.

Pre-procedure assessment

Assessment includes transvaginal pelvic ultrasound with Doppler (looking for venous dilation > 6-8 mm with reflux), pelvic MRI or venous CT angiography to map the dilated veins and search for a compressive cause (Nutcracker syndrome, left iliac vein compression). A venous CT or diagnostic phlebography may be performed at the start of the procedure.

Procedure

Under local anesthesia and light sedation, a catheter is introduced through the right internal jugular vein or femoral vein. Under fluoroscopic guidance, the interventional radiologist catheterizes the ovarian veins (left and/or right) and internal iliac veins if necessary. Phlebography confirms reflux and identifies dilated veins. Embolization is performed using coils (metallic spirals) and/or a sclerosing agent (polidocanol or sotradecol). The goal is complete occlusion of refluxing veins. The procedure takes approximately 45 to 90 minutes.

Results and scientific evidence

Studies show significant pain improvement in 70-85% of cases after embolization, with a technical success rate exceeding 95%. A systematic review including over 1,000 patients reported a 75% significant clinical improvement rate and a 40-50% complete symptom resolution rate (Laborda et al., Cardiovascular and Interventional Radiology, 2013; DOI: 10.1007/s00270-013-0586-2).

Improvement is generally gradual over 3 to 6 months. Long-term results show sustained efficacy at 5 years in the majority of cases. Recurrence rates are approximately 10-15%, often related to incomplete treatment of internal iliac veins.

Risks and complications

Complications are rare and generally minor: puncture site pain (< 5%), coil migration (< 1%, generally without consequence), transient ovarian phlebitis (< 3%, manifested by pelvic pain and fever, resolving with anti-inflammatory medication). Major complications are exceptional.

Recovery

Return to normal activities is possible within 24-48 hours. Symptom improvement is gradual over 4 to 12 weeks. Follow-up is scheduled at 1, 3, and 6 months. A control Doppler ultrasound is performed at 3 months.

Practical information

The procedure is performed as an outpatient or short inpatient stay depending on the case. It is performed by an interventional radiologist, in coordination with the treating gynecologist.