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Pelvic Congestion Syndrome and the Ovarian Vein
Pelvic Congestion Syndrome is common in women who have had children. It is associated with a range of pelvic and lower limb symptoms, including urinary urgency and urge incontinence. Ovarian Vein Embolism is a safe and effective method of treatment, and is considered the gold_standard treatment method History The presence of Pelvic varices has been well documented since 1917, with first venographic conformation of tubo-ovarian varices in 1966. Since that time there has been an evolution in the understanding of the condition. Pathophysiology During pregnancy, the Ovarian Vein dilates as a result of large increases in transuterine blood flow. Following pregnancy, the vein fails to regress to its previous size in up to 20% of women. Unsupported by uterine flows, and lacking competent valves, the vein produces reflux into dilated parovarian and pelvic veins. These veins can be associated with the bladder, uterus or ureter, producing a wide range of pelvic symptoms. The veins can form connections into the upper thigh and be associated with primary or recurrent varicose veins. Clinical Features Ovarian Vein Incompetence appears most commonly in multiparous women, but can appear after a single pregnancy Pelvic Congestion Syndrome is characterised by dysmenorrorhea, dyspareunia, urgency urge incontinence and nocturia. Symptoms are exacerbated during menstrual periods. Patients with connections into the upper thigh characteristically develop an oblique posterior thigh vein. Bladder Symptoms Patients experience urinary frequency, voiding up to 10 times a day and 5 times at night. Opportunistic voiding is common. Urge Incontinence can develop after years of uncontrolled urgency. Some patients describe renal angle pain. Investigations Transvaginal Pelvic Scans are the most accurate method of confirming ovarian vein incompetence. Indices for a positive diagnosis are: • Ovarian Vein Diameter > 4mm • Reflux in Ovarian Veins • Positive Valsalva in Pam-Ovarian veins Management Ovarian Vein Embolisation is minimally invasive, safe and effective. It is performed as a day case procedure. Technique: • Venous access is either via Right Internal Jugular Vein, or Vein • A wire is passed into the left renal and thereafter into the Left Ovarian vein • Venography is performed to document landmarks • Aethoxysclerol 3% solution injected to sclerose Pelvic Veins • Embolic Coils are place in the ovarian vein to permanently occlude the vessel Adverse Effects 36 hours after the procedure, most patients experience moderate left sided pelvic pain. This subsides after 48 hours. Some patients experience transient abdominal bloating and anorexia as a result of the retro-peritoneal inflammation. There is no evidence that ovarian function is adversely affected. Embolisation Coil Technical Problems reported in the literature are rare and include vessel wall perforation and dislodgement of coils during the procedure. Results 75 % of patients report improvement in Bladder Symptoms, with 50% of the total grading the improvement as Excellent or Good. 25% report no improvement. For patients with pelvic congestion syndrome, there is a reported improvement of 80% in pelvic symptoms. |
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