Pelvic vein disorder (PeVD) refers to a range of symptoms and signs that originate from the pelvic veins, which include the gonadal veins, internal iliac veins, and their branches, as well as the venous plexuses in the pelvis. These veins primarily drain through the left renal vein, iliac veins, and pelvic escape points [1]. Although this condition might not always pose a life-threatening risk, it can affect an individual’s quality of life and general health. Therefore, accurate diagnosis and effective management are essential to relieve symptoms, enhance quality of life, and avert complications.

The internal iliac vein and the genital vein manage the drainage of the pelvic structures. Near the ovaries and uterine tubes, the ovarian veins form a network in the broad ligament and connect with the uterine plexus. The right ovarian vein drains into the inferior vena cava (IVC), while the left one drains into the left renal vein (LRV). The ovarian veins link to the utero-ovarian and salpingo-ovarian veins through the broad ligaments and connect to the rectal, vaginal, and vesical veins. Recently, the American Vein and Lymphatic Society introduced a classification system for PeVD affecting four anatomical regions of the abdomen and pelvis [1].

1. PeVD due to primary sources of incompetence

PeVD can result from pelvic vein incompetence (PVI), which originates from the left or right gonadal veins (ovarian or testicular veins), the left or right internal iliac veins (IIVs), or a combination of these veins. Incompetent pelvic veins can affect the perineal or vulvar veins, the proximal thigh veins, or the sciatic vein, leading to varicose veins (VVs) in the lower limbs [2].

2. PeVD due to associated pathologies

PeVD might be due to PVI resulting from the right common iliac artery compressing the left common iliac vein (known as May-Thurner syndrome) or an external mass compressing iliac veins, leading to secondary reflux in pelvic veins due to increased venous pressure. This condition can lead to venous hypertension, which might cause varicose veins in the lower extremities, with or without pelvic symptoms. Extrinsic compression could also be caused by conditions like endometriosis or a tumor mass. Similar patterns of pressure and flow can often be observed in cases of post-thrombotic iliac obstruction. Another rare form of venous compression can occur when the left renal vein is compressed between the aorta and superior mesenteric artery (Nutcracker syndrome). In this situation, the increased venous pressure is alleviated through the pararenal collaterals and/or left gonadal veins, causing reflux into the pelvis and beyond [3].

1. Chronic pelvic pain

Pain symptoms can persist for over six months. This is frequently linked to adverse cognitive, behavioral, sexual, and emotional effects, along with symptoms indicating issues with the lower urinary tract, sexual function, bowel, pelvic floor, myofascial, or gynecological health [1].

2. Extrapelvic symptoms and signs

Symptoms related to reflux may occur including pain, discomfort, tenderness, itching, bleeding, and superficial venous thrombosis, particularly associated with non-saphenous varicosities in the posteromedial thigh [1]. Exertional pain can also occur in the lower extremities, often described as a tight, bursting pain in the thigh, buttocks, or leg (known as venous claudication). This pain is not linked to a specific walking distance and is limited to certain muscle groups but is relieved by rest and elevating the legs. Venous claudication symptoms are typically associated with iliocaval venous obstruction [4].

3. Renal symptoms and signs

Symptoms and signs resulting from renal vein hypertension due to left renal vein compression may occur including micro- or macrohematuria, as well as left flank pain or abdominal pain that worsens with activities like standing, sitting, or walking [5].

1. Ultrasound

Transvaginal ultrasound (TVUS) can serve as a noninvasive diagnostic tool for PeVD. Veins larger than 5 mm in diameter crossing the uterus and the presence of pelvic varices on TVUS are highly sensitive and specific for diagnosing PeVD [6]. Abdominal duplex ultrasound can detect large ovarian veins greater than 5 mm in diameter and the presence of reflux indicative of PeVD, along with direct visualization and assessment of the renal and iliac veins.

2. Computed tomographic and magnetic resonance venography

Both computed tomographic (CT) and magnetic resonance (MR) imaging can be utilized to assess abdominal and pelvic veins. On CT imaging, pelvic varices appear as dilated, tortuous, and enhanced tubular structures around the uterus and ovaries, possibly extending into the broad ligaments and pelvic sidewalls. Rozenblit et al. defined ovarian venous insufficiency on CT angiography as contrast opacification during the arterial phase and a maximum vein diameter greater than 7 mm [7]. When performing MR venography, 2D and 3D T1-weighted gradient echo sequences administered after intravenous gadolinium are considered the most effective for diagnosing pelvic varicose veins [8].

3. Catheter venography

Selective gonadal and internal iliac venography in the reverse Trendelenburg position (not in the supine position), or using the Valsalva maneuver, is the gold standard for diagnosing PVI and is crucial before embolization treatment (Fig. 1) [9]. According to Chung and Huh, venographic diagnosis of PCS due to ovarian vein valve insufficiency is based on findings such as an ovarian vein diameter greater than 5 mm, retention of contrast medium in the ovarian vein for more than 20 seconds, congestion in the pelvic venous plexus, opacification of the internal iliac veins, and/or filling of vulvar and thigh varicosities [10].

Figure 1. Refluxing left ovarian vein.

1. Medical treatment

A prospective randomized study showed that taking micronized purified flavonoid fraction, 500 mg twice daily for six months, resulted in significant improvement by the end of the treatment period [11]. Faquhar and colleagues also discovered that 30 mg of medroxyprogesterone acetate taken for six months effectively relieved pelvic symptoms, with 73% of women experiencing at least a 50% improvement, compared to 33% of women who received a placebo [12]. In a prospective randomized trial conducted by Soysal and colleagues, goserelin acetate (3.6 mg per month for six months) produced significantly better results than medroxyprogesterone [13]. However, the beneficial effects of all these treatments seemed to disappear once the treatment was discontinued.

2. Endovascular treatment

1) Reflux disease

Endovascular treatment with embolization can be an effective option with favorable outcomes for patients with PeVD caused by primary incompetence. This procedure is performed under local anesthesia and includes diagnostic venography. During the procedure, selective catheterization and contrast-enhanced study are followed by embolization of the refluxing vein or veins. Embolization is primarily done using a coil (Fig. 2) [14], and for exceptionally large veins, a vascular plug can be used [15]. Combining foam sclerotherapy with embolization can decrease the number of coils or vascular plugs needed, using foam prepared from sodium tetradecyl sulfate or polidocanol. The technical effectiveness of this procedure is estimated to be between 96% and 100%, with recurrence rates up to 32%, and embolization-related complications are rare and nonfatal [16,17].

Figure 2. Embolization of an incompetent left ovarian vein.

2) Obstructive disease

If common iliac vein obstruction (May-Thurner syndrome) is identified as the primary cause of PeVD, stenting the relevant lesion should be considered. Unlike iliac vein compression stenting, LRV stenting carries a higher risk of serious complications, including stent migration to the heart or pulmonary artery, necessitating a multidisciplinary approach for LRV compression cases.

3. Other treatment options

Various surgical methods have been reported for treatment of PeVD, such as ligation of the ovarian and/or IIVs, ligation of the ovarian and uterine arteries and veins, oophorectomy, and even total hysterectomy with bilateral salpingo-oophorectomy [18]. While combining bilateral oophorectomy with hysterectomy and hormone replacement therapy has proven effective for patients unresponsive to medical treatments [19], this approach is quite invasive and may not be suitable for women who wish to become pregnant.

Treatment methods for each category are summarized in Table 1.

Table 1 . Treatment options for pelvic vein disorder.

Category	Treatment method
Medical treatment*	- Micronized purified flavonoid fraction: 500 mg twice daily for six months showed significant symptom improvement [11]
	- Medroxyprogesterone acetate: 30 mg for six months, 73% of women had ≥50% symptom improvement [12]
	- Goserelin acetate: 3.6 mg per month for six months showed better results than medroxyprogesterone [13]
Endovascular treatment	- Reflux disease: Embolization under local anesthesia with coils or vascular plugs; technical effectiveness 96%–100%, recurrence up to 32% [14-17]
	- Obstructive disease: Stenting for common iliac vein obstruction; careful approach needed for left renal vein stenting due to higher complication risk
Other treatment options	- Surgical methods: Ligation of ovarian or internal iliac veins, oophorectomy, and hysterectomy with bilateral salpingo-oophorectomy have been reported [18]

*Benefits of medical treatments generally disappear after discontinuation..

In 2011, clinical guidelines including recommendation on PeVD treatment were published by the Society for Vascular Surgery and the American Venous Forum. These guidelines advise using coil embolization, plugs, or percutaneous sclerotherapy, either alone or in combination, to treat PeVD and pelvic varices caused by pelvic venous insufficiency (Grade 2B) [20]. In 2022, the European Society for Vascular Surgery released guidelines on managing chronic venous disease of the lower limbs. These guidelines suggest that for patients with pelvic-origin varicose veins and pelvic symptoms needing treatment, pelvic vein embolization should be considered to alleviate symptoms [21].

PeVD significantly affects individuals’ quality of life, with chronic pelvic pain being common symptom. Effective management of PeVD involves a combination of accurate diagnostic imaging and tailored treatments. Medical therapies offer temporary relief, while endovascular treatments with embolization provide lasting benefits. Optimal treatment based on the background pathophysiology is needed to manage the complex nature of PeVD.

The author declares no conflicts of interest.