Pelvic varicosities are widely prevalent among women who have borne children, and in some
Cases can lead to chronic pelvic pain --- especially when associated with the
ovarian veins. This article describes a simple radiologic technique for both diagnosis and
treatment in patients with suggestive symptoms.Chronic pelvic pain is a common complaint
among female patients of reproductive age that often defies simple diagnosis and
treatment. In many cases, It significantly interferes with the ability to perform daily
activities and leads to discomfort during sexual intercourse. Defined as noncyclic
abdominal and pelvic pain of at least 6 months duration. Chronic pelvic pain may persist
for years without relief. This syndrome and its many potentially adverse psychosocial
outcomes thus represent a primary health concern for women.
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INTERVENTIONAL RADIOLOGY
Some patients find relief from
chronic pelvic pain after ovarian vein embolization treatment by interventional radiology.
Results of a study of 22 women treated with ovarian vein embolization were recently
reported. All of the subjects suffered chronic pelvic pain that became worse during the
course of the day especially after standing for long periods of time. Most reported a
full/heavy sensation that led to severe pain. After ovarian vein embolization, 16 patients
reported a marked improvement or complete resolution of their painful symptoms.
All patients underwent ovarian
venography in the upright position to ascertain the presence of ovarian varicoceles. The
venogram is a key component to diagnosis because tests routinely performed for chronic
pelvic pain --- including laparoscopy and ultrasonography --- typically do not demonstrate
ovarian varicoceles. This is partially because they may not directly image the ovarian
veins and also because these procedures are typically performed with the patient lying
down.
INCIDENCE
In one nonclinical sample of 651
women the prevalence of chronic pelvic pain was found to be 12%, and the lifetime
occurrence rate was 33%. Women with chronic pelvic pain am a heterogeneous group, with the
disorder transcending racial, educational, and socioeconornic boundaries.
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CAUSES
Chronic pelvic pain can result from
a variety of conditions including endometriosis, pelvic adhesions, pelvic inflammation,
urinary tract abnormalities, musculoskeletal conditions, bacterial or fungal infections,
anatomic conditions, and psychosocial problems. When a thorough history, clinical
evaluation, and/or treatment plan fail to identify a cause, the authors recommend
consultation with an interventional radiologist to determine whether varicose veins from
the ovary --- a frequently overlooked diagnosis --- may be the cause of chronic pelvic
pain.
An estimated 150,000 to 200,000
American women, especially those who have borne more than one child, have varicose veins
around the ovaries, uterus, and other reproductive organs. While up to 15% of all women
have varicose veins within the pelvis, only some develop a pain syndrome: this can vary
from a mild sensation of heaviness to severe debilitating pain. It has been suggested that
the painful sensation experienced by manly women results from the enlargement of the veins
and engorgement of the surrounding tissues that is often seen with ovarian varicoceles.
In one study, 10 women with chronic
pelvic pain who had normal laparoscopic findings but demonstrated venous congestion on
venography were found to have a significantly greater variation in vaginal temperature
changes compared with control subjects. Continuing research --- including venographic
studies in women with this condition --- may lead to a better understanding and definition
of pelvic varicosities as a cause of pelvic pain and yield scientific criteria for its
diagnosis.
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INDICATIONS
Patients suffering from chronic
pelvic pain should be considered for ovarian venography and potential ovarian vein
embolization only after undergoing thorough examination by their primary physician. In
addition, other possible causes should first be excluded by laparoscopy and pelvic
ultrasonography. Common symptoms of ovarian vancoccles include:
- Pelvic pain that worsens toward the
end of the day with progressive pelvic tissue engorgement;
- Pain during or after intercourse;
- Pelvic pain that worsens after long
periods of standing;
- A feeling of pelvic oppression or
heaviness;
- Varicose veins of the vulva; and
- Varicose veins of the leg that recur
despite repeated surgery.
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METHODS
Standard tests for diagnosing
pelvic pain (eg, laparoscopy, pelvic ultrasonography) that are performed with the patient
supine are rarely able to detect even large pelvic varicoceles. Ovarian venography should
be performed with the patient in an upright position. The patient first lays down on the
x-ray table, and a catheter is inserted through the jugular or femoral vein and advanced
into the ovarian vein under local anesthesia. When the catheter is appropriately
positioned, the x-ray table is tilted into an upright position and a contrast medium is
injected. With this approach, the interventional radiologist can ascertain the direction
of blood flow and determine the presence of abnormal veins.
Depending on patient and referring
physician preference, venography can remain solely a diagnostic tool, with the treatment
of any detected ovarian varicoceles left for a separate occasion. In most cases. However,
ovarian vein embolization, is performed as part of the same procedure once a definitive
diagnostic is obtained. The interventional radiologist extrudes small stainless steel
coils through the catheter into the ovarian vein, occluding the vein and preventing reflux
of blood via the ovarian vein into the pelvis.
Ovarian vein embolization is
usually performed on an outpatient or day-care basis. It takes approximately I hour
followed by I hour of recovery. In most cases, patients are able to walk immediately after
the procedure and resume most daily activities. Patients are typically restricted from
performing heavy lifting and vigorous exercise for approximately 3 days post procedure.
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RESULTS AND COMPLICATIONS
No complications or significant
adverse effects were reported in the study of 22 patients who underwent ovarian vein
embolization. Ten patients reported complete resolution of symptoms. Six reported a
significant improvement of pain; they were able to function normally without pain
medication, but continued to report mild discomfort. Six patients reported no improvement
or only slight improvement in pain and required continued medication. Some patients noted
absolute immediate improvement in symptoms, while others noted improvement after a delay
of up to 5 months. These results are expected, as it has been reported that removing the
cause of pain in chronic pain syndromes does not always result in instant relief.
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CONCLUSION
Patients should be counseled about
realistic expectations when undergoing treatment for chronic pelvic pain. In our
experience, many patients-particularly those who have suffered for long periods without
relief-often prefer a surgical approach to treatment minimally invasive interventional
radiology. Although surgery is an important partt of the repertoire available for treating
chronic pelvic pain, it is appropriate only in carefully evaluated and selected patient.
Despite its extensive use, there
are no controlled trials evaluating the long-term effectiveness of a hysterectomy for
chronic pelvic pain. Indeed approximately 25% of women referred for evaluation of chronic
pelvic pain have already undergone hvsterectomy witth no resolution of symptoms. The
pressure to use increasingly expensive and invasive tests and procedures must be balanced
against an assessment and understanding of the basic dynamics of the patient with chronic
pelvic pain. As a result. a multidisciplinary approach to the management of these patients
--- including evaluation by an interventional radiologist --- -is gaining increasing
acceptance.
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REFERENCES
- Milburn A. Reiter RC. Rhomberg A
Multidisciplinary approach to chronic pelvic pain. Obster Gynecol Clin North Am
1993:20(4):643
- Machan L. Gvnecalogical
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al The prevalence of chronic pain and irritable bowel syndrome in two university clinics.
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pelvic pain. Obstet Gynecol Clin North Am 1993:20(4):635.
- Thomas DC. Stones RW. Forquhar CM,
et al
Measurement of pelvic blood flow
changes in response to postion in normal subjects and in women with pelvic pain owing to
congestion by using a thermal technique. Clin Sei. 1992:83:55.
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- Beard RW, Reginald Pw. Wadsworth J.
Clinical features of women with chronic lower abdominal pain and pelvic congestion, Br J
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- Parsons LH. Stovall TG. Surgical
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- Slocumb JC. Operative management of
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Lindsay
Machan, MD, is an Associate Professor of Radiology at the University of
British Columbia and Head of Angioplasty and Interventional Radiology at Vancouver
Hospital and Health Sciences Centre. UBC Site in Vancouver, British Columbia, Canada.
Robert
Vogelzang, MD, is a Professor of Radiology at Northwestern University Medical
School and Chief of Vascular and Interventional Radiology at Northwestern Memorial
Hospital in Chicago.
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