Pelvic Congestion Syndrome (PCS): Definition, Causes and Diagnosis

What is pelvic congestion syndrome?

Pelvic congestion syndrome (PCS) is a frequently unrecognised cause of chronic pelvic pain in women, due to pathological dilation of the ovarian and uterine veins (internal pelvic varices). Venous stasis causes congestion of the pelvic organs, responsible for dull chronic pain or a feeling of pelvic heaviness.

PCS mainly affects women of childbearing age who have had several pregnancies, and is often under-diagnosed because the varices are internal (not visible) and the symptoms are non-specific.

🔍 Does your ultrasound or MRI report mention one of these terms?

Certain wordings in a radiology report point towards pelvic congestion syndrome and justify a specialist opinion:

Causes and mechanisms

Dilation of the pelvic veins results from valve incompetence of the ovarian veins (especially the left), which causes venous reflux towards the pelvis. Contributing factors are:

• Multiparity: repeated pregnancies dilate the ovarian veins
• Ovarian varicocele: the female equivalent of male varicocele
• Compression of the left renal vein (nutcracker syndrome)
• Compression of the left iliac vein (May-Thurner syndrome)

Symptoms of PCS

• Chronic pelvic pain (> 6 months), dull, with a feeling of heaviness, worse when standing for long periods, at the end of the day, during periods or after intercourse
• Dyspareunia (pain during sexual intercourse)
• Dysmenorrhoea
• Visible varices on the inner thighs, labia majora or buttock region
• Partial relief when lying down

A benign condition, but with a major impact

PCS is a benign condition that requires no emergency management. Its course is slow, comparable to that of varicose veins of the lower limbs, and sometimes remains stable over time. However, poorly relieved chronic pain can, in the long run, affect mood (anxiety, irritability, sometimes depression) and personal, professional or couple life. Drug treatments can partially relieve the symptoms, but do not treat the cause of the syndrome.

Treatment: endovascular embolization

The reference treatment for PCS is endovascular embolization, a minimally invasive procedure performed by an interventional radiologist:

• Performed under local anaesthesia, through a puncture (most often in the groin crease), for about 1 hour
• Consists of closing the incompetent pelvic veins using a sclerosing foam and/or a medical glue
• Eliminates the venous reflux responsible for blood stagnation and therefore pain
• The indication is made by the interventional radiologist during a dedicated consultation

During injection of the sclerosing agent, lower abdominal pain similar to the usual attacks may occur for a few seconds; the team warns the patient at each step, and painkillers and anti-sickness drugs are given beforehand to limit this sensation.

After the procedure and recovery

• Outpatient monitoring for 2 to 3 hours after the procedure, with a visit from the radiologist before discharge
• One day of rest is recommended, then sick leave of about one week
• Transient pain may appear in the first 72 hours, usually resolving during the first week; anti-inflammatory drugs and painkillers are prescribed if needed
• A home nursing visit is usually offered for the first 2-3 days
• Physical and sporting activities, and any effort that increases abdominal pressure, should be avoided during the first week
• Complications are rare

Results and follow-up

Embolization produces a significant improvement in symptoms in about 80 to 90% of patients after one or two procedures, with, in published series, a fall in pain intensity from about 7/10 to 2/10 and a clear improvement in quality of life. Its efficacy depends on the mechanism of the pain, the medical and surgical history, and how long the symptoms have been present before treatment.

A consultation with a follow-up MRI is scheduled 3 months after the procedure to assess the efficacy of the treatment and the possible need for further embolization. The radiologist remains available by email for any question after the procedure.

Fertility and pregnancy

The available studies have shown no negative impact of PCS embolization on fertility or on future pregnancies.

Varices during pregnancy: what to do?

During pregnancy, the increase in blood volume needed for the development of the fetus dilates the veins of the pelvis, and the enlarged uterus mechanically slows venous return from the lower limbs: varices (vulvar, buttock, leg) may then appear. They most often regress, totally or partially, after delivery.

It is recommended to wait 3 to 4 months after delivery before consulting for a venous insufficiency work-up, so that the situation can stabilise naturally.

Frequently asked questions