tempPhlebology OnlineFirst, published on May 6, 2013 as doi:10.1258/phleb.2012.012067
Short report
Pelvic congestion syndrome diagnosed using endoscopic ultrasonography S J Cho*, T H Lee*, K Y Shim*, S S Hong† and D E Goo†
*Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital; †Department of Radiology, Soonchunhyang College of Medicine, Seoul, Republic of Korea
Abstract Pelvic congestion syndrome (PCS) presents with a non-cyclic pelvic pain lasting more than six months in duration in premenopausal women. Pelvic ultrasonography or computed tomography is usually the first imaging modality used to evaluate patients with suspected PCS. PCS is confirmed by visible congestion of the pelvic veins on selective ovarian venography. To our knowledge, the role of endoscopic ultrasonography (EUS) has not been reported. EUS showed multiple dilated structures especially on left side around the uterus and ovaries, which are compatible with other radiological investigations of PCS Although PCS is not typical areas within the scope of practice of endosonographers, it is useful to be familiar with the findings. We report a case of PCS that was diagnosed with the aid of EUS. Keywords: endoscopic ultrasonography; pelvic congestion syndrome
Introduction Pelvic congestion syndrome (PCS) is a condition characterized by visible congestion of the pelvic veins on selective ovarian venography in multiparous, premenopausal women with a history of chronic pelvic pain for more than six months.1 Pelvic ultrasonography (US) or computed tomography (CT) is usually the first imaging modality used to evaluate patients with suspected PCS. To our knowledge, the role of endoscopic ultrasonography (EUS) has not been reported. We report a case of PCS that was diagnosed with the aid of EUS.
Report A 36-year-old multiparous woman was referred to our hospital for the evaluation of a one-year history of lower abdominal pain and dyspareunia. She had recently undergone a colonoscopy to Correspondence: Tae Hee Lee MD, Institute for Digestive Research, Soonchunhyang University, College of Medicine, Deasagwan-gil 22, Yongsan-gu, Seoul, Republic of Korea. Email: [email protected] Accepted 14 August 2012
assess acute diarrhoea and was diagnosed with extrinsic compression of the rectum. On admission, she had tenderness in the left lower quadrant. EUS was performed to evaluate the extrinsic compression of the rectum using an electronic radial-type echoendoscope (EG-3670 URK; Pentax, Tokyo, Japan). This examination revealed a subepithelial lesion in the rectum resulting from extrinsic compression by the cervix. Interestingly, multiple dilated structures were identified around the uterus and ovaries, especially on the left side (Figure 1). Based on the clinical and EUS findings, we performed additional investigations, including abdominopelvic CT, to determine the best means of managing the PCS. CT showed tortuous engorgement of the left parauterine venous plexus (Figure 2). To relieve the PCS, percutaneous pelvic vein embolization was performed at the time of diagnostic venography using coils (Figure 3). The patient’s lower abdominal pain and dyspareunia were resolved completely following the embolotherapy.
Discussion Women with chronic lower abdominal pain constitute a substantial proportion of the workload of DOI: 10.1258/phleb.2012.012067. Phlebology 2012:1–3
Downloaded from phl.sagepub.com at FUDAN UNIV LIB on May 17, 2015
Short report
S J Cho et al. EUS of pelvic congestion syndrome
Figure 3 Pelvic venography showing embolization therapy. (a) Retrograde ovarian vein flow is visible. (b) Dilated, tortuous left ovarian veins and several tortuous collateral pelvic veins are visible. (c) Pelvic vein embolization therapy was performed with coils Figure 1 Endoscopic ultrasound showing multiple dilated structures, especially involving the left adnexa
gynaecologists and gastroenterologists. PCS is an important gynaecological disease in the differential diagnosis of chronic lower abdominal pain. The diagnosis of PCS continues to challenge all physicians. Therefore, increased awareness and clinical suspicion of the symptoms and associated findings can enable optimal treatment of the disease. Patients commonly present with pelvic pain without evidence of inflammatory disease.2 This pain may be worsened by the following: sitting, standing, at the end of the day, during or after intercourse (dyspareunia), or just before the onset of menses.3 Affected women may have generalized lethargy, depression, abdominal or pelvic tenderness, vaginal discharge, dysmenorrheal, swollen
Figure 2 Abdominopelvic computed tomography image showing diffuse enlargement of the left gonadal vein, with bilateral tortuous engorgement of the parauterine venous plexus and arterial reflux
2
vulva, lumbosacral neuropathy, rectal discomfort or urinary frequency.3 Signs detected on examination may include vulval varicosities which extend on to the medial thigh and long saphenous territory. Tenderness may be elicited by deep palpation at the ovarian point (the point where the upper third meets the lower two-thirds of an imaginary line from the anterior superior iliac spine to the umbilicus).4 A variety of radiological imaging modalities can be used to diagnose PCS, including US, CT and magnetic resonance imaging. These examinations demonstrate the typical finding of severe dilation of the gonadal venous system.3 The US and CT provide an excellent resolution of the uterus. Although a CT scan has greater sensitivity for showing varicosities throughout the lower pelvis, US with Doppler examination provides a dynamic information about the visualized venous blood flow. Criteria for the sonographic diagnosis of varices includes (1) the visualization of dilated ovarian veins greater than 4 mm in diameter, (2) dilated tortuous arcuate veins in the myometrium that communicate with bilateral pelvic varicose veins, (3) slow blood flow (less than 3 cm/ second) and (4) reversed caudal or retrograde venous blood flow particularly in the left ovarian vein.1 The diagnosis of PCS is confirmed by pelvic venography showing an ovarian vein diameter .6 mm, retrograde ovarian venous flow, the presence of several tortuous collateral pelvic venous pathways and delayed clearance of contrast at the end of injection. The relevance of EUS in the diagnosis of gynaecological diseases is unknown. EUS can image pelvic pathology in addition to anorectal disease, including endometriosis5 and adnexal masses.6 In our patient, EUS showed multiple dilated structures around the uterus and ovaries, especially on the
Phlebology 2012:1–3 Downloaded from phl.sagepub.com at FUDAN UNIV LIB on May 17, 2015
S J Cho et al. EUS of pelvic congestion syndrome
left side. These findings were compatible with those of other radiological investigations of PCS.
Short report
References 1
Conclusions EUS is not included in classic diagnostic algorithms of the PCS. EUS can provide an excellent resolution of the uterus and associated organs without the exposure of radiation. In the hands of an endosonographers, rectal EUS can play an important role in the diagnosis of the PCS during the work-up of the other diseases such as rectal cancer. Although endosonographers do not typically encounter PCS, their familiarity with the findings of this disease is useful. Author contributions: THL contributed to this work. KYS collected data and drafted the paper. SJC wrote the paper. SSH and DEG reviewed data analysis and corrected research design. Conflict of interest: All authors disclosed no financial relationships relevant to this manuscript.
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Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;2:946– 9 Ganeshan A, Upponi S, Hon LQ, Uthappa MC Warakaulle DR, Uberoi R. Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Intervent Radiol 2007;30:1105 – 11 Ignacio EA, Dua R, Sarin S, et al. Pelvic congestion syndrome: diagnosis and treatment. Semin Intervent Radiol 2008;25:361– 8 Freedman J, Ganeshan A, Crowe PM. Pelvic congestion syndrome: the role of interventional radiology in the treatment of chronic pelvic pain. Postgrad Med J 2010;86:704 – 10 Delpy R, Barthet M, Gasmi M, et al. Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum. Endoscopy 2005;37:357– 61 Moparty B, Gomez G, Bhutani MS. Large solitary ovarian metastasis from colorectal cancer diagnosed by endoscopic ultrasound. World J Gastroenterol 2008;14:5096– 7
Phlebology 2012:1–3 Downloaded from phl.sagepub.com at FUDAN UNIV LIB on May 17, 2015
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Short report
Pelvic congestion syndrome diagnosed using endoscopic ultrasonography S J Cho*, T H Lee*, K Y Shim*, S S Hong† and D E Goo†
*Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital; †Department of Radiology, Soonchunhyang College of Medicine, Seoul, Republic of Korea
Abstract Pelvic congestion syndrome (PCS) presents with a non-cyclic pelvic pain lasting more than six months in duration in premenopausal women. Pelvic ultrasonography or computed tomography is usually the first imaging modality used to evaluate patients with suspected PCS. PCS is confirmed by visible congestion of the pelvic veins on selective ovarian venography. To our knowledge, the role of endoscopic ultrasonography (EUS) has not been reported. EUS showed multiple dilated structures especially on left side around the uterus and ovaries, which are compatible with other radiological investigations of PCS Although PCS is not typical areas within the scope of practice of endosonographers, it is useful to be familiar with the findings. We report a case of PCS that was diagnosed with the aid of EUS. Keywords: endoscopic ultrasonography; pelvic congestion syndrome
Introduction Pelvic congestion syndrome (PCS) is a condition characterized by visible congestion of the pelvic veins on selective ovarian venography in multiparous, premenopausal women with a history of chronic pelvic pain for more than six months.1 Pelvic ultrasonography (US) or computed tomography (CT) is usually the first imaging modality used to evaluate patients with suspected PCS. To our knowledge, the role of endoscopic ultrasonography (EUS) has not been reported. We report a case of PCS that was diagnosed with the aid of EUS.
Report A 36-year-old multiparous woman was referred to our hospital for the evaluation of a one-year history of lower abdominal pain and dyspareunia. She had recently undergone a colonoscopy to Correspondence: Tae Hee Lee MD, Institute for Digestive Research, Soonchunhyang University, College of Medicine, Deasagwan-gil 22, Yongsan-gu, Seoul, Republic of Korea. Email: [email protected] Accepted 14 August 2012
assess acute diarrhoea and was diagnosed with extrinsic compression of the rectum. On admission, she had tenderness in the left lower quadrant. EUS was performed to evaluate the extrinsic compression of the rectum using an electronic radial-type echoendoscope (EG-3670 URK; Pentax, Tokyo, Japan). This examination revealed a subepithelial lesion in the rectum resulting from extrinsic compression by the cervix. Interestingly, multiple dilated structures were identified around the uterus and ovaries, especially on the left side (Figure 1). Based on the clinical and EUS findings, we performed additional investigations, including abdominopelvic CT, to determine the best means of managing the PCS. CT showed tortuous engorgement of the left parauterine venous plexus (Figure 2). To relieve the PCS, percutaneous pelvic vein embolization was performed at the time of diagnostic venography using coils (Figure 3). The patient’s lower abdominal pain and dyspareunia were resolved completely following the embolotherapy.
Discussion Women with chronic lower abdominal pain constitute a substantial proportion of the workload of DOI: 10.1258/phleb.2012.012067. Phlebology 2012:1–3
Downloaded from phl.sagepub.com at FUDAN UNIV LIB on May 17, 2015
Short report
S J Cho et al. EUS of pelvic congestion syndrome
Figure 3 Pelvic venography showing embolization therapy. (a) Retrograde ovarian vein flow is visible. (b) Dilated, tortuous left ovarian veins and several tortuous collateral pelvic veins are visible. (c) Pelvic vein embolization therapy was performed with coils Figure 1 Endoscopic ultrasound showing multiple dilated structures, especially involving the left adnexa
gynaecologists and gastroenterologists. PCS is an important gynaecological disease in the differential diagnosis of chronic lower abdominal pain. The diagnosis of PCS continues to challenge all physicians. Therefore, increased awareness and clinical suspicion of the symptoms and associated findings can enable optimal treatment of the disease. Patients commonly present with pelvic pain without evidence of inflammatory disease.2 This pain may be worsened by the following: sitting, standing, at the end of the day, during or after intercourse (dyspareunia), or just before the onset of menses.3 Affected women may have generalized lethargy, depression, abdominal or pelvic tenderness, vaginal discharge, dysmenorrheal, swollen
Figure 2 Abdominopelvic computed tomography image showing diffuse enlargement of the left gonadal vein, with bilateral tortuous engorgement of the parauterine venous plexus and arterial reflux
2
vulva, lumbosacral neuropathy, rectal discomfort or urinary frequency.3 Signs detected on examination may include vulval varicosities which extend on to the medial thigh and long saphenous territory. Tenderness may be elicited by deep palpation at the ovarian point (the point where the upper third meets the lower two-thirds of an imaginary line from the anterior superior iliac spine to the umbilicus).4 A variety of radiological imaging modalities can be used to diagnose PCS, including US, CT and magnetic resonance imaging. These examinations demonstrate the typical finding of severe dilation of the gonadal venous system.3 The US and CT provide an excellent resolution of the uterus. Although a CT scan has greater sensitivity for showing varicosities throughout the lower pelvis, US with Doppler examination provides a dynamic information about the visualized venous blood flow. Criteria for the sonographic diagnosis of varices includes (1) the visualization of dilated ovarian veins greater than 4 mm in diameter, (2) dilated tortuous arcuate veins in the myometrium that communicate with bilateral pelvic varicose veins, (3) slow blood flow (less than 3 cm/ second) and (4) reversed caudal or retrograde venous blood flow particularly in the left ovarian vein.1 The diagnosis of PCS is confirmed by pelvic venography showing an ovarian vein diameter .6 mm, retrograde ovarian venous flow, the presence of several tortuous collateral pelvic venous pathways and delayed clearance of contrast at the end of injection. The relevance of EUS in the diagnosis of gynaecological diseases is unknown. EUS can image pelvic pathology in addition to anorectal disease, including endometriosis5 and adnexal masses.6 In our patient, EUS showed multiple dilated structures around the uterus and ovaries, especially on the
Phlebology 2012:1–3 Downloaded from phl.sagepub.com at FUDAN UNIV LIB on May 17, 2015
S J Cho et al. EUS of pelvic congestion syndrome
left side. These findings were compatible with those of other radiological investigations of PCS.
Short report
References 1
Conclusions EUS is not included in classic diagnostic algorithms of the PCS. EUS can provide an excellent resolution of the uterus and associated organs without the exposure of radiation. In the hands of an endosonographers, rectal EUS can play an important role in the diagnosis of the PCS during the work-up of the other diseases such as rectal cancer. Although endosonographers do not typically encounter PCS, their familiarity with the findings of this disease is useful. Author contributions: THL contributed to this work. KYS collected data and drafted the paper. SJC wrote the paper. SSH and DEG reviewed data analysis and corrected research design. Conflict of interest: All authors disclosed no financial relationships relevant to this manuscript.
2
3
4
5
6
Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;2:946– 9 Ganeshan A, Upponi S, Hon LQ, Uthappa MC Warakaulle DR, Uberoi R. Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology. Cardiovasc Intervent Radiol 2007;30:1105 – 11 Ignacio EA, Dua R, Sarin S, et al. Pelvic congestion syndrome: diagnosis and treatment. Semin Intervent Radiol 2008;25:361– 8 Freedman J, Ganeshan A, Crowe PM. Pelvic congestion syndrome: the role of interventional radiology in the treatment of chronic pelvic pain. Postgrad Med J 2010;86:704 – 10 Delpy R, Barthet M, Gasmi M, et al. Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum. Endoscopy 2005;37:357– 61 Moparty B, Gomez G, Bhutani MS. Large solitary ovarian metastasis from colorectal cancer diagnosed by endoscopic ultrasound. World J Gastroenterol 2008;14:5096– 7
Phlebology 2012:1–3 Downloaded from phl.sagepub.com at FUDAN UNIV LIB on May 17, 2015
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