I am so excited to talk about pelvic congestion syndrome. Since February I’ve been asking a lot of questions about this and I’ve really opened my eyes to see that this really is a part of the pelvic pain picture for many of my patients. Correcting pelvic congestion isn’t terribly difficult and it can create a significant, if not complete, reduction in pelvic pain for some women.
Pelvic congestion is such a weird name – I both love and hate it. I love it because some women say they feel “congestion” in their “pelvis” which makes perfect sense. I hate the term because it also sounds so ambiguous. Of course the pelvis is congested, there is a ton of stuff just shoved in there – like a Thanksgiving turkey.
What is pelvic congestion? This is when the pelvic veins have enlarged so much that the valves that are supposed to be responsible for one way movement of blood are no longer doing their job. This means that the blood goes both up and down. When you get this two-directional movement in a vein it is considered to be demonstrating “reflux”. When the veins are super distended, they are also called varicosities. You’ve seen this before when you’ve been in a long line at the movies. There’s that one overweight guy in shorts and he’s got that crazy purple vein bulging out. It’s sticking out an inch away from the rest of his skin. That’s a varicosity. That’s what’s happening in your pelvis when you have pelvic congestion. Okay, so not to that drastic degree, but you get the picture.
What are the symptoms of pelvic congestion? The traditional symptoms will be listed below, but remember that everyone is different. I think that doctors are taking a look at your collection of symptoms and then determining if you should move forward with diagnostic testing.
- pressure in abdomen/pelvis
- pain in the legs
- pressure or pain in abdomen/pelvis/legs that gets worse at the end of the day
- pressure or pain in abdomen/pelvis/legs that improves with lying down
- pressure or pain in vulvar area or legs from pressing on abdomen or doing valsava (bearing down hard)
- assymmetrical labias that became assymmetrical later in life
- pain with sexual intercourse
- pain with periods (or history of pain with periods)
- urinary frequency or urgency
- veins in the pelvis that are really easy to see
- spider veins in the legs
How can pelvic congestion effect my pelvic pain if I have pudendal neuralgia? If you have pelvic congestion alone, this can cause pelvic pain. If you have pelvic congestions and sitting pain symptoms caused by pelvic nerves, then the dilated nerve can press on the pudendal nerve irritating it even further. This situation is interesting because it’s like peeling away the layers of an onion in order to get rid of your pain. It’s a step-wise process.
How is pelvic congestion diagnosed? Gynecologists can diagnose this, but usually it’s interventional radiologists who are specializing in vein stuff. If you just google pelvic congestion, you might find that there are a number of ways to diagnose this including MRI, ultrasound and venography. There are pros and cons of these techniques, so I think it makes sense that you understand them because each physician is going to tell you something slightly different. That being said, this is just my take on the procedures.
- MRI – This is a picture of your pelvic veins over a 15 minute period. This can be effected by what you ate, where your are on your cycle or any other number of factors. I believe that if your MRI is negative, that does not rule out the possibility that you have pelvic congestion. Some doctors will look at a negative MRI and tell you flat out that you don’t have pelvic congestion. This is a little narrow minded and I recommend if you are in this situation that you get a second opinion from a doctor that doesn’t follow the same thought process.
- Ultrasound – A vaginal ultrasound can show varicosities in pelvic veins, but the best opportunity to see this will be at the end of the day and while you are standing. I have had patients do an ultrasound, but they aren’t standing. So – I don’t know why we even bother if you are going to stay on your back. Feel free to question why you are having a lying down ultrasound. Don’t waste your time or your money.
- Venogram – Dye is injected into the veins so that your doctor can see if you’ve got distended veins. If you do, it will be clear to see if there are just a few that are an issue or if there are a whole lot of problems. This is considered the best way to diagnose pelvic congestion syndrome. This can be done with you asleep, so ask how your doctor does this.
How is pelvic congestion treated? Typically this is treated via embolization and/or sclerotization. Embolization is when coils are placed in the vein – usually during the venogram. Then, sclerotization is when a foam is injected into the stretched out vein so that it basically solidifies and the body absorbs it. The blood will then go through all the smaller veins. The pressure is relieved because you don’t have these bigger honker veins pulsing and throbbing creating pressure and cramping.
How did I get pelvic congestion? Typically this results from a backwards movement of the blood in the veins that are supposed to leave the ovaries. This can be hormonal a lot of the time. The hormones from pregnancy cause a lot of relaxation in the body and this effects the pelvic veins. Estrogen levels can make the veins more lax. Typically women who have multiple pregnancies will experience this because of the increased blood volume in the pelvis, but women without any pregnancies can definitely get this too. According to Dr. Andrew Goldstein, Dr. Irwin Goldstein and Dr. Caroline Pukall, authors of When Sex Hurts, all of this is the same reason women get hemorrhoids during pregnancy. They say a hemorrhoid is basically a varicose vein.
My doctor doesn’t believe in pelvic congestion! Ya’ll, we’re not asking your doctor to believe in the tooth fairy. If your doctor doesn’t think that your set of symptoms could be due to varicosities in the pelvic veins, find a doctor who does think that this exists in the realm of possibilities for you. To overlook something that could be as “simple” as this is really unfortunate. There is a lot of hullabaloo that pelvic congestions is a “vague” and “ambiguous” diagnosis, but you know that your pain isn’t “vague” and “ambiguous”. I think that pelvic congestion syndrome is a contributing factor to a lot of pelvic pain, and like I said before, for some people it can be the only issue they have.
If you have any questions, please email me at Sara@sullivanphysicaltherapy.com or leave your question in the comment section below.