title: Diagnosis and treatment of the pelvic congestion syndrome.
abstract: BACKGROUND
  Chronic pelvic pain accounts for up to 30% of outpatient gynecologic visits in the United States, potentially affecting up to 40% of the female population during their lifetime. Pelvic congestion syndrome (PCS) is defined as chronic pelvic pain resulting from reflux or obstruction of the gonadal, gluteal, or periuterine veins, sometimes associated with perineal or vulvar varices. It can also be caused by compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, also known as the nutcracker syndrome. Whereas PCS accounts for up to 30% of patients presenting with chronic pelvic pain, it is frequently underdiagnosed. We reviewed the literature to investigate the current state of the diagnosis and treatment of this disorder.
  
  
  METHODS
  An online database search was performed with MEDLINE. MeSH headings included PCS, chronic pelvic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies.
  
  
  RESULTS
  Our MEDLINE search revealed more than 3756 references to chronic pelvic pain. Specific references to PCS, pelvic chronic pain, ovarian vein reflux, nutcracker syndrome, renal vein obstruction, pelvic varicosities, labial varicosities, embolization, treatment, and therapies, however, included only 260 references. Thirty-seven references were small series including fewer than 50 patients or individual case reports documenting medical, surgical, or endovascular treatment of PCS. The majority of these papers demonstrated successful treatment of symptoms from PCS with embolization of one or both ovarian veins in addition to treatment of refluxing internal iliac vein branches. In addition, open surgery and, more recently, endovascular stenting of LRV obstruction have shown some promise in alleviating symptoms attributed to nutcracker syndrome.
  
  
  CONCLUSIONS
  Diagnosis of PCS requires a careful history, physical examination, and noninvasive imaging. Several large case series have demonstrated the efficacy of embolotherapy in the reduction of pelvic pain; thus, it is the most favored treatment option for patients with PCS. For patients with outflow obstruction due to nutcracker syndrome, a limited number of studies have demonstrated remission of symptoms with stenting of the LRV as an alternative to open surgery.
authors.affiliation: Division of Vascular Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY.
authors.forename: Marlene T
authors.initials: MT
authors.lastname: O'Brien
authors.affiliation: Division of Vascular and Endovascular Surgery, Heart and Vascular Center, Southcoast Healthcare System, Charlton Hospital, Fall River, Mass. Electronic address: gillespied@southcoast.org.
authors.forename: David L
authors.initials: DL
authors.lastname: Gillespie
mesh_terms: D059350:Chronic Pain / Q000175:diagnosis / Q000628:therapy; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D010053:Ovary / Q000098:blood supply; D017699:Pelvic Pain / Q000175:diagnosis / Q000628:therapy; D012082:Renal Veins; D013577:Syndrome; D014648:Varicose Veins