Pelvic congestion syndrome
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The Pelvic Congestion Syndrome is based on the venous congestion in the pelvic area, mainly in the so-called small (deep) pelvis. There are two ways of its development.

In the simplest case, the veins that drain the blood from the pelvis into the inferior vena cava are too narrow, compressed or blocked.
In addition, blood from the left renal vein can be diverted into small pelvic organs (see “Nutcracker Syndrome”) and then contribute to the overload of the pelvic veins.

Often both possibilities combine and lead to particularly strong symptoms.

Frequent symptoms of pelvic venous congestion are:

  1. abdominal pain (often left-sided)
  2. severe pain in the pelvic area (between the symphysis and the navel)
  3. increased menstrual cramps
  4. strong or stronger menstrual bleeding
  5. pain during sexual intercourse (dyspareunia)
  6. pain in the external genitals – sometimes indiscernable from pudendal nerve entrapment (pudendal neuralgia)
  7. permanent unpleasant sexual arousal
  8. congestion in the genital area (especially in women who had multiple deliveries)
  9. swelling of the vulva – permanent tension within the vulva
  10. pain during bowel movements
  11. urgency and painful urination
  12. bloody urine (mostly as invisible traces, detectbale only under the microscope or with a urine test strip – microhematuria)
  13. hemorrhoids – bleeding during defecation
  14. deep anal pain
  15. varicose veins in the groin and on the external genitalia
  16. fullness an weakness of the left, later also of the right leg
  17. swollen legs
  18. thrombosis – often predominantly of the left leg
  19. erectile dysfunction – sometimes priapism (unpleasant long-lasting penile erection)
  20. varicocele (filling of the scrotal sac with wormlike venous vessels – sometimes painful, often uncomfortable, sometimes interfering with spermiogenesis)

 

The chronically over-stretched veins meander as so-called varices (“varicose veins” – varix is of Latin origin and means knobby, dilated vein) and cause pain and discomfort emerging in the wall of the vein and in the congested organs as well. Many women (and postpubertal girls) complain of pain in the left lower abdomen (area of the left ovary) and men complain about discomfort and pain in left testicle.

Sketch of typical collateral pathways: The blood from the left kidney runs against the nutcracker, then turns downwards via the left ovarian vein into the vast pool of retroperitoneal veins around the uterus. From there, via the veins on the right side of the uterus, it reaches the inferior vena cava(MR angiogram)

Upper abdominal cross section – view from below In MR angiography and ultrasound, the congestion of the consecutively enlarged left renal vein is shown along with path of the blood through a tronc réno-rachidien to the veins of the spinal column, in- and outside

Representation of the left-sided collateral veins along the spinal column and cord in MR angiography

In pelvic congestion, pain in the lower abdomen or in the left testicle results from the diversion of blood from the left kidney to the organs of the pelvis. This blood is drained via the ascending lumbar vein and the left ovarian (in males*: spermatic) vein into the pelvis. This additional volume needs to be transported to the inferior vena cava, which runs at the right side of the spine. Within the pelvis a vast network of veins fills the space between the organs, mainly the uterus (prostate*), rectum, urinary bladder and vagina. This network takes up the renal blood from the left kidney but may soon be overfilled. If so, complaints emerge. These consist mainly of painful sensations at rest, during voiding, bowel movements, menstruation or sexual intercourse. Sometimes bleeding occurs from the hemorrhoidal venous plexus of the anus, sometimes bloody urine is observed. Voiding may be very urgent and frequent resulting in little amounts of urine only. This situation is very often misinterpreted as urinary bladder inflammation, infection or pyelonephritis, especially since red blood cells are often found in the urine, but white blood cells, characteristic for all kinds of inflammation, are missing.
The pressure in the deep pelvic veins may rise to an amount that the main left sided pelvic vein, the left common iliac vein may be filled mainly by the blood coming from the left kidney. Since the left common iliac vein also takes up blood from the left leg, via the left external iliac vein, this blood may be partially blocked. A congestion of the left leg, left thigh and the left parts of the genitalia results. In women with multiple pregnancies, varices of the left groin, tenderness and pain may result. Sometimes a fullness of the clitoris and the labia majora and minora with unsolicited sexual arousal occurs and may be bothering. Thrombosis of the deep veins of the left leg, mainly of the calf, and varices of the left leg may develop.
To get access to the inferior vena cava, left renal blood is thus pressed partly across deep veins of the pelvic plexus, partly across the left common iliac vein.  But this large vessel may also be blocked in persons who have a strong lumbar lordosis. In this case the promontory is especially prominent and sticks out frontally into the pelvis from behind. This compression of the left common iliac vein by the overlying right common iliac artery against the promontory is known, after its first description by two Swiss physicians, as May-Thurner-constellation.

A more detailed desription of vascular compression syndromes can be downloaded here.

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