2. 03/19/15 2
overlooked & underdiagnosedoverlooked & underdiagnosed
common gynecologic pathologycommon gynecologic pathology
Pelvic
congestion
syndrome
one-third of all women will experienceone-third of all women will experience
chronic pelvic pain in their lifetimes.chronic pelvic pain in their lifetimes.
27% of consultation in gynecology27% of consultation in gynecology
30% unknown etiology30% unknown etiology
60% pelvic varicosity60% pelvic varicosity
10% different pathologies :10% different pathologies :
Endometerios, Adenomyosis, Fibroids,Endometerios, Adenomyosis, Fibroids,
Gartner cyst, PeriurethralGartner cyst, Periurethral cystscysts andand
Pudendal nerve compressionPudendal nerve compression
3. 03/19/15 3
Syrian nationalSyrian national
prevalence study 2005prevalence study 2005
Pelvic
congestion
syndrome
Global results;Global results;
- 46% of 20-40 years women (930/2024) complain of- 46% of 20-40 years women (930/2024) complain of
some clinical aspects of PCSsome clinical aspects of PCS
PCS confirmed (CT, Duplex or phlebography) in 53%PCS confirmed (CT, Duplex or phlebography) in 53%
(379/715) of suffering women(379/715) of suffering women
-The most common symptoms:-The most common symptoms:
lower abdominal & pelvic pain 34%lower abdominal & pelvic pain 34%
dyspareunia 19% !!!dyspareunia 19% !!!
urinary troubles 12%urinary troubles 12%
atypical varicose veins 9%atypical varicose veins 9%
- Only 22% of suffering women have- Only 22% of suffering women have
ever consulted for PCS symptomsever consulted for PCS symptoms
- Very rarely PCS diagnosis was established- Very rarely PCS diagnosis was established
4. 03/19/15 4
Syrian nationalSyrian national
prevalence study 2005prevalence study 2005
Pelvic
congestion
syndrome
ConclusionsConclusions
- Higher prevalence of PCS in Syrian female population than in- Higher prevalence of PCS in Syrian female population than in
Western countries maybe due to High number of pregnancies,Western countries maybe due to High number of pregnancies,
marriages in the same family in Syria and to the style of life.marriages in the same family in Syria and to the style of life.
- Difficulties to approach PVC with young Syrian women due to- Difficulties to approach PVC with young Syrian women due to
traditional taboos.traditional taboos.
- Gynecologists often wrongly attribute PCS symptoms to some- Gynecologists often wrongly attribute PCS symptoms to some
psychical or local neural ambiguous reasons.psychical or local neural ambiguous reasons.
RecommendationsRecommendations
Further studies need to be confirmed by echography or C.TFurther studies need to be confirmed by echography or C.T
Gynecologists and general practitionersGynecologists and general practitioners
must be better informed about the PCS in medical schools andmust be better informed about the PCS in medical schools and
postgraduate continuous education programspostgraduate continuous education programs
Oriental women may have better access to some kind ofOriental women may have better access to some kind of
education concerning their sexualityeducation concerning their sexuality
5. 03/19/15 5
Clinical aspectsClinical aspectsPelvic
congestion
syndrome
Multiparity,Multiparity, child-bearingchild-bearing ageage
Chronic lower abdomen and lowerChronic lower abdomen and lower
back dull painback dull pain
Dyspareunia, DysmenorrheaDyspareunia, Dysmenorrhea
Dysuria, PolyuriaDysuria, Polyuria
Tenesmus, ConstipationTenesmus, Constipation
Vaginal exam:Vaginal exam:
Big & congestive uterusBig & congestive uterus
Painful neck mobilizationPainful neck mobilization
Retroversion in 20% of casesRetroversion in 20% of cases
Perineal , vulval , buttock , atypicalPerineal , vulval , buttock , atypical
posterior or recurrent varicose veinsposterior or recurrent varicose veins
6. 03/19/15 6
Pelvic Venous AnatomyPelvic Venous Anatomy
Internal Iliac veinsInternal Iliac veins
- Parietal & Visceral brunches- Parietal & Visceral brunches
- in 27% of cases 2 separate trunks- in 27% of cases 2 separate trunks
- trunk valves 10%, brunches 9%- trunk valves 10%, brunches 9%
Ovarian veinsOvarian veins
-- reunion of 4-5 trunksreunion of 4-5 trunks
- at right IVC- at right IVC
- at left LRV- at left LRV
Ureteric veinsUreteric veins
- tributaries of ovarian veins- tributaries of ovarian veins
- relatively rare- relatively rare
Segmental pelvic veinsSegmental pelvic veins
- no shrinkage of uterine & broad ligament- no shrinkage of uterine & broad ligament
veins after pregnancies !veins after pregnancies !
Pelvic
congestion
syndrome
14. 03/19/15 14
Endovascular approachEndovascular approach
techniquestechniques
Pelvic
congestion
syndrome
Coils embolizationCoils embolization
Expensive, cannot treat huge veins nor collateralsExpensive, cannot treat huge veins nor collaterals
Boiled materiel sclerosisBoiled materiel sclerosis
Painful (must be proceeded and combined with intravenousPainful (must be proceeded and combined with intravenous
diluted Xylocain injection)diluted Xylocain injection)
Liquid sclerosisLiquid sclerosis
May need important sclerosing agent dose or the usage of anMay need important sclerosing agent dose or the usage of an
occlusive balloon catheterocclusive balloon catheter
Foam sclerosisFoam sclerosis
Good efficacy with small sclerosing agent dose, meticulousGood efficacy with small sclerosing agent dose, meticulous
technique to avoid complicationtechnique to avoid complication
Above techniques CombinationAbove techniques Combination (boiled contrast+Foam)(boiled contrast+Foam)
15. 03/19/15 15
Endovascular approachEndovascular approach
techniquetechnique
Pelvic
congestion
syndrome
Phlebo-cartographyPhlebo-cartography
Local anesthesia + urethralLocal anesthesia + urethral cathetercatheter
Sedation, analgesicsSedation, analgesics
Access :Access :
Femoral (Femoral (copra + simons cathcopra + simons cath))
Jugular (Jugular (multipurpose cathmultipurpose cath))
Looking for obstructive syndromes by ilio-cavalLooking for obstructive syndromes by ilio-caval
opacification (opacification (bigatel cathbigatel cath))
4 vessels selective opacification :2ovarian + 2IIVs4 vessels selective opacification :2ovarian + 2IIVs
((Valsalva deep inspirationValsalva deep inspiration) using a tilting table) using a tilting table
in case of atypical or recurrent lower limbs varicosein case of atypical or recurrent lower limbs varicose
veins; bilateralveins; bilateral descending femoral veins phlebographydescending femoral veins phlebography
16. 03/19/15 16
TechniqueTechniquePelvic
congestion
syndrome
Selective or supraselective vein 4-6 f catheterizationSelective or supraselective vein 4-6 f catheterization
over a 35 hydrophilic wire, beginning with the most distalover a 35 hydrophilic wire, beginning with the most distal
vein partvein part
In case of difficult catheterization by femoral accessIn case of difficult catheterization by femoral access
use a 6-8f renal guiding catheter support, (MP guid-cathuse a 6-8f renal guiding catheter support, (MP guid-cath
for jugular approach)for jugular approach)
In case of huge ovarian veins use prior boiled contrastIn case of huge ovarian veins use prior boiled contrast
technique:technique:
transcatheter vein filling with(transcatheter vein filling with(Xylocain+contast agent+salineXylocain+contast agent+saline))
mixturemixture
five minutes later lent injection of some boiled contrastfive minutes later lent injection of some boiled contrast
till obtaining moderate vein spasm (preferable usage oftill obtaining moderate vein spasm (preferable usage of
glassy syringes)glassy syringes)
17. 03/19/15 17
TechniqueTechniquePelvic
congestion
syndrome
Slow injection of foam contrast mixture (Slow injection of foam contrast mixture ( 2 ml of 3%2 ml of 3%
sclerosing agent “STS or Polidocanol” + 1 ml of contrast agent + 2sclerosing agent “STS or Polidocanol” + 1 ml of contrast agent + 2
ml saline + 15 ml air Tssari’s method agitatedml saline + 15 ml air Tssari’s method agitated) distally then) distally then
more and more proximallymore and more proximally
Be sure that all principal collaterals are treated, if notBe sure that all principal collaterals are treated, if not
do supraselective catheterizationdo supraselective catheterization
Never inject in internal iliac veins or trunks, injectNever inject in internal iliac veins or trunks, inject
only in branchesonly in branches
When no more contrast can be injected and there isWhen no more contrast can be injected and there is
constant contrast stagnation, wait 3 minutes beforeconstant contrast stagnation, wait 3 minutes before
pulling out the catheterpulling out the catheter
One hour after procedure patient is asked to walk forOne hour after procedure patient is asked to walk for
10 minutes then discharged10 minutes then discharged
18. 03/19/15 18
Boiled contrast techniqueBoiled contrast technique
right ovarian vein incontinenceright ovarian vein incontinence
Pelvic
congestion
syndrome
24 years24 years
Recurrent rightRecurrent right
lower limblower limb
varicose veinvaricose vein
after surgeryafter surgery
DysmenorrheaDysmenorrhea
19. 03/19/15 19
Left ovarian veinLeft ovarian vein
incontinenceincontinence
Pelvic
congestion
syndrome
39 years39 years
DyspareuniaDyspareunia
Lower backLower back
painpain
26. 03/19/15 26
Scleromousse techniqueScleromousse techniquePelvic
congestion
syndrome
Complications :Complications :
variable postembolization syndrome (24-72 h)variable postembolization syndrome (24-72 h)
mild pelvic and dorsal pain, fever, nauseamild pelvic and dorsal pain, fever, nausea
rare hematomas, extravasations, DVT, allergyrare hematomas, extravasations, DVT, allergy
chest malaise is frequent but extremely rarechest malaise is frequent but extremely rare
gas embolismgas embolism (pulmonary, neurologic or optical)(pulmonary, neurologic or optical)
General results :General results :
95-100% procedure success95-100% procedure success
50-60 % complete pain resolution50-60 % complete pain resolution
25-40 % pain amelioration25-40 % pain amelioration
10-30% symptoms recurrence in tow years10-30% symptoms recurrence in tow years
27. 03/19/15 27
ConclusionsConclusionsPelvic
congestion
syndrome
Overlooked &Overlooked & UnderdiagnosedUnderdiagnosed commoncommon
GynecologicGynecologic pathologypathology
Major cause of women's invalidism andMajor cause of women's invalidism and
both sex postsurgical varicose veins recurrenceboth sex postsurgical varicose veins recurrence
Reflux Endovascular treatment is effective,Reflux Endovascular treatment is effective,
noninvasive, well tolerated & repetitivenoninvasive, well tolerated & repetitive
Foam sclerotherapy is safe & non expensiveFoam sclerotherapy is safe & non expensive
Satisfactory results but experience dependantSatisfactory results but experience dependant
Pelvic Congestion Syndrome is
