Chronic Pelvic Pain (CPP) in women is extremely common. So common that it accounts for up to 40% of visits to Gynecologists and 15% of Family Practitioners. CPP is defined as non-cyclic pain lasting more than six months in duration. The list of medical conditions associated with CPP is long, typically requiring a team of physicians to correctly determine which part of the body requires a more detailed evaluation and treatment. Many women have undergone medical and surgical treatment with little or no relief. One of the more commonly overlooked diagnoses is called Pelvic Venous Insufficiency (PVI) or Pelvic Congestion Syndrome.
PELVIC VENOUS INSUFFICIENCY, SYMPTOMS:
- Heavy cramping pelvic pain that increases after intercourse and towards the end of the day.
- Lying down flat or elevating the pelvis with pillows improves the sensation of heaviness; the pain is virtually gone upon awakening in the morning following a night of restful restorative sleep.
- Some women experience bowel and bladder symptoms due to venous congestion.
- Some women will have venous varices in the upper thighs, genital region, or buttocks.
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WHAT CAUSES PELVIC VENOUS INSUFFICIENCY?
PVI results when the veins that drains the ovaries begins to flow in the wrong direction. This type of venous insufficiency is common, affecting 10% of women. Up to sixty percent of women with these broken veins will experience the classic symptoms including, but not limited to: a dull pelvic ache, constant pelvic pain that worsens with standing, a heaviness or fullness in the pelvis that progressively worsens throughout the day, and deep pelvic pain following intercourse. Urinary urgency and bowel symptoms may also be associated with these findings.
A common question asked is, “Why do these veins break?” Unfortunately, there is no one simple answer. It is likely a combination of the ovarian vein being exposed to high concentrations of estrogen and progesterone over multiple menstrual cycles, dilation of the vein in response to pregnancy, and dysfunction of the venous valves – the support structure that makes the vein a one-way street.
WE CAN DIAGNOSE OR RULE OUT PVI
Fortunately, the diagnosis can be verified by painless and non-invasive imaging such as Magnetic Resonance Venography, a very specific type of MRI, and ultrasound. Once this diagnosis is confirmed, these veins can be treated with small metal coils (imagine the spring on the inside of a pen) that prevent the blood from flowing in the wrong direction. The procedure is performed in an outpatient setting with a rapid recovery.
As described on this page, Pelvic Venous Insufficiency (PVI) represents a fundamental problem with the valves in the gonadal or ovarian veins. This condition was described a long time ago and was previously known as Pelvic Congestion Syndrome. Due to the emotional overlay ascribed to the latter term, we currently refer to this condition as Pelvic Venous Insufficiency. Either term can be used to describe the same fundamental flaw in the venous valves, and there can certainly be a resultant emotional component to living with daily pelvic pain. However, the term Pelvic Venous Insufficiency accurately describes the condition without associating the term negatively with anxiety, depression, or both. Therefore, we use the term Pelvic Venous Insufficiency to avoid the potential labeling of a patient’s experience with this disease process.
PELVIC VENOUS INSUFFICIENCY, MEDICAL IMAGING:
- Magnetic Resonance Venography is a painless type of MRI that can help visualize the physiologic aspects of arterial and venous blood flow with a small amount of contrast injected through an intravenous line.
- Transabdominal and transvaginal ultrasound can detect enlarged and dilated veins in the pelvis, giving insight to whether or not venous disease should be included in the workup for chronic pelvic pain
PELVIC VENOUS INSUFFICIENCY, TREATMENT, TECHNICAL ASPECTS:
The goal of eliminating gonadal venous reflux is aimed at re-routing the flow of venous blood away from the pelvis and eradicating the incompetent veins.
A small sterile catheter (imagine a very fine drinking straw) is inserted into the incompetent gonadal veins using X-ray guidance from a tiny incision in the groin or neck. Contrast dye is injected into the veins to document that the blood is indeed flowing in the wrong direction. Once confirmed, small coils (imagine the tiny spring in a ballpoint pen) are deployed into the vein, again using X-ray guidance to block the flow of blood.
Once the appropriate veins are blocked, the blood is re-routed to the central venous drainage.
This process stops the blood from flowing through the broken veins, thus alleviating the venous pooling in the pelvis thereby decreasing pain and discomfort.
Dr. Charles Bowkley has been treating this condition in Wyoming since 2010. If you have experienced the symptoms above or would like more information, please do not hesitate to contact Casper Medical Imaging.