Pelvic Congestion Syndrome

Definition

Pelvic Congestion Syndrome (PCS) is characterised by chronic pelvic pain associated with the presence of dilated pelvic veins and venous stasis. The aetiology involves ovarian dysfunction leading to excessive local oestrogen production, which causes dilation and stasis in the pelvic veins. Commonly, PCS presents in the reproductive age group, with a mean age of diagnosis around 33 years​​.

PCS is a condition that often presents diagnostic challenges, mainly due to its varied and nonspecific symptoms. The term ‘Pelvic Congestion Syndrome’ itself is not universally accepted, as there is ongoing debate within the medical community regarding its precise definition and diagnostic criteria. Some experts prefer the term ‘Chronic Pelvic Pain Syndrome’ as it encompasses a broader range of chronic pelvic pain without attributing it solely to venous congestion. This broader term acknowledges the multifactorial nature of chronic pelvic pain and allows for a more inclusive diagnostic approach, accommodating various underlying pathologies that might not strictly align with the vascular abnormalities typically associated with PCS, or accepting that sometimes no clear pathology is found.

Epidemiology

The epidemiological data specific to the UK is limited. Globally, PCS is a common cause of chronic pelvic pain, especially in women who have been pregnant multiple times. However, precise prevalence rates are challenging to ascertain due to variability in diagnostic criteria and reporting.

Diagnosis

Clinical Features: PCS typically presents as a dull, aching pain in the pelvis, which is exacerbated by activities increasing intra-abdominal pressure and relieved by lying down. Other features may include deep dyspareunia, dysmenorrhea, and post-coital ache. Physical examination may reveal tenderness over the ovaries, and a blue colouration of the vagina and cervix due to vein congestion ​​.

Investigations: Differential diagnosis includes endometriosis and pelvic inflammatory disease, thus requiring thorough investigation. Venography is the definitive radiological investigation for PCS, showing dilated uterine and ovarian veins with reduced venous clearance of contrast medium​​.

Treatment

Treatment options include both medical and surgical interventions:

1. Medical Treatment:
   • Medroxyprogesterone acetate (MPA): Administered orally at 30 mg per day for 6 months, MPA suppresses ovarian function, reducing pelvic congestion and pain. However, benefits may be short-lived.
   • Gonadorelin analogues: Goserelin, 3.6 mg per month for 6 months, has shown improvement in symptoms, sexual functioning, and reduction in anxiety and depression in women with PCS​​.
2. Surgical Treatment:
   • Bilateral ovarian vein ligation.
   • Hysterectomy with bilateral salpingo-oophrectomy, followed by hormone replacement therapy​​.
3. Pain management.

In some cases, a more holistic pain-management approach is required

Prognosis

The prognosis for PCS varies. While medical management can provide symptomatic relief, the chronic nature of the condition means symptoms may recur, especially after cessation of treatment. Surgical options might offer more permanent solutions but come with their inherent risks and considerations. It is essential for GPs to discuss the chronicity of PCS and the potential need for long-term management with patients.