Pelvic Congestion Syndrome Q&A with Dr. Black
Pelvic congestion syndrome, also called pelvic venous congestion, falls under a broader range of pelvic venous disorders which are a known, but often unrecognized cause of chronic pelvic pain.
Dr. Carl M. Black sat down for an interview answering some common questions about pelvic congestion syndrome.
Introduction
Dr. Black: My name is Carl Black, I am a board-certified interventional radiologist, and I have been with IVC since its start, almost 20 years ago.
Dr. Carl M. Black is fellowship-trained and board certified in interventional radiology. His expertise includes treatment of disorders of arterial and venous circulation, acute stroke intervention, and therapeutic embolization.
What is pelvic congestion syndrome (PCS)?
Dr. Black: Pelvic congestion syndrome is the term that’s most commonly used by the public for an entity that causes chronic pelvic pain and discomfort. It’s part of a spectrum of pelvic venous disorders that create an increased pressure inside the veins in the pelvis that can push on the ovaries and the uterus and create chronic nagging pain.
Are there other names for PCS?
Dr. Black: So pelvic congestion syndrome is also known as pelvic venous hypertension, pelvic venous congestion, and more recently, the preferred term is pelvic venous disorder. And the reason we refer to it as a pelvic venous disorder is that the congestion or increased pressure in the veins in the pelvis can be caused by reflux, perhaps a leaky valve in one of the ovarian veins. Or it can be caused by an obstruction of a vein that would normally take blood out of the pelvis. We have to evaluate all potential causes of pelvic congestion to make sure we can tailor a therapy to a specific patient and meet their needs.
What are the symptoms of PCS?
Dr. Black: The symptoms of pelvic congestion syndrome are mainly chronic, dull, heaviness in the pelvis. Patients will often feel that pain more toward the end of the day after they have been on their feet for a long period of time. They will feel better in the morning. It’s often reproducible simply by position, whether they are standing or laying down. Sometimes after sexual intercourse, it can have a prolonged nagging pain. But probably the most common symptom someone describes is a chronic nagging heaviness in the pelvis. It’s estimated that of patients with pelvic pain that go undiagnosed, almost 30% of those patients will have at least some element of pelvic congestion.
How do you diagnose PCS?
Dr. Black: Diagnosing and managing pelvic congestion, it’s important that we evaluate all possibilities. We want to make sure someone does not have a problem with a tumor or a problem with their ovary or some other issue. Maybe it could be chronic inflammation in the pelvis. Maybe it could be an adhesion or a scar from a prior surgery. We do thorough imaging work up that includes ultrasound where we look in a detailed way at the uterus, at the ovaries, and the other structures in the pelvis. We can also use tools such as venography that looks at the actual blood flow inside of these veins and in that way, we can with almost 90% certainty know that someone has pelvic congestion and that is the cause of their pain or some other entity that we need to help them get to another specialist to treat.
Who does PCS typically affect?
Dr. Black: Pelvic congestion usually affects women in their childbearing years. It is often women who have had multiple children. Pregnancy is a stressor on the body, on the physiology and tends to put a lot of pressure on the veins in the pelvis. So physiologically after several pregnancies, if somebody is going to develop pelvic congestion, pregnancy will often exacerbate those symptoms and bring it to the forefront.
Up to 30% of patients with chronic pelvic pain have a pelvic venous disorder.
How is PCS treated?
Dr. Black: We treat pelvic congestion typically with embolization. An embolization is an occlusion of the diseased vein. Once we have gone through our diagnostic steps and we understand what is going on with an individual patient, we can drive a catheter inside of those veins. Those diseased veins, using imaging guidance. And using coils and different substances such as a sclerosant we can occlude these disease veins so that blood no longer pools in the pelvis and causes pain. In some cases, patients may have an obstruction of a large vein that would typically drain the pelvis. Such as an iliac vein that may drain the leg. In those cases, we would put in a stent to open up that vein to relieve the pressure. So, embolization is our primary treatment, I would say, in most of our cases.
How is embolization performed?
Dr. Black: Embolization of pelvic congestion is performed using a minimally invasive procedure where we take a catheter, a small tube, and we guide it inside of the vein that’s actually diseased. The vein that has refluxing valves or insufficient valves. Once we are in that vein, and we can confirm the typical pattern of blood flow, we can then occlude that vein using a combination of small coils and a substance called a sclerosant. That combination will close and scar the vein down so that blood can no longer pool in the pelvis and cause chronic pain.
Is embolization painful?
Dr. Black: Embolization can cause mild discomfort in the pelvis. That can linger for a few days to a few weeks. We typically tell patients to wait 2-3 months before they see the full impact of embolization on their condition. We perform embolization with sedation. Meaning that we give patients medication to help them relax and feel less anxious about their procedure. And that usually takes the edge of enough the procedure is comfortable and patients tolerate it very well.
Does embolization affect fertility?
Dr. Black: Embolization does not affect fertility. Research has shown that it does not affect the function of the ovaries or the normal physiology of someone’s body. Patients can have successful pregnancies and continue to have normal menstrual cycles after embolization.
Are there any restrictions post-treatment?
Dr. Black: The recovery from embolization is usually quite straightforward. After we are done in our clinic, we will keep patients 1-2 hours, mostly to make sure they recover from sedation appropriately. Once they are home, we encourage patients to stay very active. In fact, we would like them to resume most normal daily activities after they leave our clinic. Because they have received sedation, we don’t want anybody driving or making important decisions the day of their procedure. But after that, they can pretty much resume most normal activities. For about 2 weeks, we want patients to avoid heavy lifting because we do not want to stress those veins we are trying to close down.
How long before the patient feels relief?
Dr. Black: They will generally receive their full benefit at about 2-3 months after the procedure.
How effective is PCS treatment?
Dr. Black: Our treatment of pelvic congestion is successful in over 85% of patients. It’s not 100%. And the reason it’s not 100% is pelvic pain is complex. Lots of things can cause pelvic pain but in patients who have a typical history and go through the steps that we take to confirm that diagnosis, 85% of those patients will feel significant relief and have an excellent outcome. The other 15% may have other issues that we need to refer them to a gynecologist to treat or there may be some other issue we can treat that are unrelated to pelvic congestion. Such as a tumor on the uterus, such as a fibroid, that we will treat through embolization.
