Pelvic Varices

Discussion of magnetic resonance imaging and magnetic resonance neurography

Pelvic Varices

Postby rick » Wed Jan 18, 2012 8:52 am

I had a 3T MRI done by Dr. Potter 1/4/2012.

One of her findings was that "At the pelvic floor and dorsal margin of the penis there are markedly dilated varices ... compressing the dorsal nerves to the penis bilaterally, left greater than right."

I have noticed the discussion as to whether or not nerves can be compressed by veins.

[size=150]1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117410/[/size]
Copyright © 2006 BMJ Publishing Group

Pudendal nerve compression by pelvic varices successful treatment with transcatheter ovarian vein embolisation
T Moser, M‐C Scheiber‐Nogueira, T S Nogueira, A Doll, C Jahn, and R Beaujeux
T Moser, M‐C Scheiber‐Nogueira, T S Nogueira, A Doll, C Jahn, R Beaujeux, CHU Strasbourg, Strasbourg, France
Correspondence to: Dr T Moser
CHU Strasbourg, Strasbourg 67000, France; moser_th@yahoo.fr
Keywords: embolisation, pelvic varices, pudendal nerve

A 37 year old woman complained of chronic perineal pain and numbness for three years. Physical examination was unremarkable, but perineal neurophysiological testing revealed isolated abnormalities of the left pudendal nerve. The distal motor latency and the left bulbocavernous reflex latency were both lengthened (5.3 ms; normal <3.5 ms and 48 ms; normal <42 ms, respectively). Previous laparoscopy for tubal ligation also described bilateral ovarian varices more prominent on the left side, which were confirmed at pelvic CT (fig 1A1A).



Figure 1 37 year old woman with left pudendal nerve compression by pelvic varices successfully treated with transcatheter ovarian vein embolisation. (A) Contrast enhanced CT scan through the ischial spine shows left ovarian varices (arrow). (B) (more ...)

Diagnosis of Alcock syndrome was rejected because pain was not exacerbated while seated, but rather in the upright position.1 Although perineal pain has not been reported in pelvic congestion syndrome,2 the possibility of venous compression resulting in nerve damage was raised. The patient was then referred to undergo an ovarian phlebography with possible subsequent embolisation.3 The phlebogram disclosed an enlarged left ovarian vein with congestion of the ovarian plexus (fig 1B1B)) and selective left ovarian vein embolisation was performed with coils and glue (fig 1C1C).). Three months later, our patient began to notice marked reduction in perineal pain and numbness. Neurophysiologial examination performed eight months after embolisation demonstrated normalisation of the left pudendal nerve distal motor latency.
This report suggests for the first time the possible compression of the pudendal nerve by pelvic varices, and should be analysed in line with other recently reported nervous compression cases of venous origin.4,5 It also demonstrates the dramatic relief obtained after ovarian vein embolisation
Rr
1. Ramsden C E, McDaniel M C, Harmon R L. et al Pudendal nerve entrapment as source of intractable perineal pain. Am J Phys Med Rehabil 2003. 82479–484.484. [PubMed]
2. Hobbs J T. The pelvic congestion syndrome. Br J Hosp Med 1990. 43200–206.206. [PubMed]
3. Maleux G, Stockx L, Wilms G. et al Ovarian vein embolization for the treatment of pelvic congestion syndrome: long‐term technical and clinical results. J Vasc Interv Radiol 2000. 11859–864.864. [PubMed]
4. Bendszus M, Rieckmann P, Perez J. et al Painful vascular compression syndrome of the sciatic nerve caused by gluteal varicosities. Neurology 2003. 61985–987.987. [PubMed]
5. Yamamoto N, Koyano K. Neurovascular compression of the common peroneal nerve by varicose veins. Eur J Vasc Endovasc Surg 2004. 28335–338.338. [PubMed]

2. http://im.unboundmedicine.com/medicine/ ... c_varices_
Pelvic congestion syndrome
Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices.
Authors
Liddle AD, Davies AH
Institution
Department of Surgery, St Mary's Hospital, UK.
Source
Phlebology 2007; 22(3) :100-4.
Abstract
Chronic pelvic pain is a common and disabling condition affecting women of childbearing age. A specific diagnosis for the condition is often difficult, and referred pain from the abdominal viscera, neurogenic and psychogenic factors have all been implicated, as have pelvic conditions such as endometriosis, pelvic inflammatory disease and ovarian cysts; no diagnosis is made in 60% of patients. Pelvic congestion syndrome (PCS), the presence of varices of the pelvic veins, has been shown to be the underlying aetiology in a significant proportion of patients with chronic pelvic pain; the development of these varices is caused by a combination of endocrine and mechanical factors. Given the positional nature of these varices, they are rarely diagnosed with conventional methods such as B-mode ultrasound and diagnostic laparoscopy. Diagnosis is best made with selective ovarian venography, although newer, non-invasive methods such as magnetic resonance imaging and duplex ultrasound are increasingly gaining favour. Pelvic varices are eminently treatable, either using ovarian suppression or by the ligation or embolization of the pelvic veins.
Mesh
Chronic Disease
Female
Humans
Iliac Vein
Ovary
Pain Measurement
Pelvic Pain
Pelvis
Syndrome
Varicose Veins
Language
eng
Pub Type(s)
Journal Article Review
PubMed ID
18268860

3. http://www.sirweb.org/patients/chronic-pelvic-pain/

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Pelvic Congestion Syndrome - Chronic Pelvic Pain in Women
Non-Surgical Procedure is Effective Treatment for Painful Ovarian Varicose Veins
It is estimated that one-third of all women will experience chronic pelvic pain in their lifetime. Many of these women are told the problem is "all in their head" but recent advancements now show the pain may be due to hard to detect varicose veins in the pelvis, known as pelvic congestion syndrome.
The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don't close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.
The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing.
Many women with pelvic congestion syndrome, spend many years trying to get an answer to why they have this chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.
If you have pelvic pain that worsens throughout the day when standing, you may want to seek a second opinion with an interventional radiologist, who can work with your gynecologist. You can ask for a referral from your doctor, call the radiology department of any hospital and ask for interventional radiology or visit the doctor finder link at the top of this page to locate a doctor near you.
Prevalence
• Women with pelvic congestion syndrome are typically less than 45 years old and in their child bearing years.
• Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
• Chronic pelvic pain accounts for 15% of outpatient gynecologic visits.
• Studies show 30% of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15% have PCS along with another pelvic pathology.
Risk Factors
• Two or more pregnancies and hormonal increases
• Fullness of leg veins
• Polycystic ovaries
• Hormonal dysfunction
Symptoms
The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:
• Following intercourse
• Menstrual periods
• When tired or when standing (worse at end of day)
• Pregnancy
Other symptoms include:
• Irritable bladder
• Abnormal menstrual bleeding
• Vaginal discharge
• Varicose veins on vulva, buttocks or thigh.
Diagnosis and Assessment
Once other abnormalities or inflammation has been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods. An interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use the following imaging techniques to confirm pelvic varicose veins that could be causing chronic pain.
Pelvic venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, interventional radiologists examine patients on an incline, because the veins decrease in size when a woman is lying flat.
MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.
Pelvic ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done is an very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.
Transvaginal ultrasound: This technique is used to see better inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems.
Treatment Options
Once a diagnosis is made, if the patient is symptomatic, an embolization should be done. Embolization is a minimally invasive procedure performed by interventional radiologists using imaging for guidance. During the outpatient procedure, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the femoral vein in the groin and guides it to the affected vein using X-ray guidance. To seal the faulty, enlarged vein and relieve painful pressure, an interventional radiologist inserts tiny coils often with a sclerosing agent (the same type of material used to treat varicose veins) to close the vein. After treatment, patients can return to normal activities immediately.
Additional treatments are available depending on the severity of the woman's symptoms. Analgesics may be prescribed to reduce the pain. Hormones such birth control pills decrease a woman's hormone level causing menstruation to stop may be helpful in controlling her symptoms. Surgical options include a hysterectomy with removal of ovaries, and tying off or removing the veins.
Efficacy
In addition to being less expensive to surgery and much less invasive, embolization offers a safe, effective, minimally invasive treatment option that restores patients to normal. The procedure is very commonly successful in blocking the abnormal blood flow. It is successfully performed in 95-100 percent of cases. A large percentage of women have improvement in their symptoms, between 85-95 percent of women are improved after the procedure. Although women are usually improved, the veins are never normal and in some cases other pelvic veins are also affected which may require further treatment.

Copyright © 2012

I have an appointment for embolization February 2nd.

Rick
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Re: Pelvic Varices

Postby Violet M » Sun Jan 22, 2012 4:19 am

Rick, this is a big step for you as I know you've been avoiding surgery successfully for a long time with medications. I wish you all the best with your procedure and hope to hear some good news back form you soon. ;)

Best,

Violet M
PNE since 2002. Started from weightlifting. PNE surgery from Dr. Bautrant, Oct 2004. Pain now is usually a 0 and I can sit for hours on certain chairs. No longer take medication for PNE. Can work full time and do "The Firm" exercise program. 99% cured from PGAD. PNE surgery was right for me but it might not be for you. Do your research.
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Re: Pelvic Varices

Postby kia kaha » Thu Jan 26, 2012 3:41 pm

thanks Rick for posting that

informative..
the last case, worse when tired, after intercourse etc a couple of my symptoms..
but pipe dreams bringing this option up with the docs here
Chronic Pain pudendal area for 3 years, after a hard jolt to right side.
18 months later discovered sprained/fused sacro-illiac injury. Told to 'live with it' then saw this forum October 2011 = symptoms matched. Attempting to get this investigated in the face of lack of skilled docs in New Zealand.
Been told I have IC Dec 2011
FINALLY - 3T MRI in Christchurch 5th May 2012 - Pudendal nerve block, unguided 8th June 2012 - still waiting on results and progress from these.
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Re: Pelvic Varices

Postby davemon1953 » Wed Feb 01, 2012 11:31 pm

I had the embolization three months ago for large deep pelvic varices. It was not the cure, so far. Anyone know how long to see results? Doc said 3-6 months but that sounds too long.
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Re: Pelvic Varices

Postby donstore » Thu Feb 02, 2012 7:04 am

Good luck, Rick.
Mild to moderate PN for 5 plus years, pain controlled by lyrica and opiates.
Nerve block (unguided) 9/10 Dr. Jerome Weiss - sciatica for 5 months but got numb in painful perineal/scrotal area - he diagnosed entrapment - but no more cortisone for me
Potter MRI 5/11 - rt STL entrapment of PN at Alcocks
Consult with Dr. Hibner Feb. 2012
Bilateral inguinal hernias diagnosed by dynamic ultrasound - surgery on 6/20/13
Feeling a little better, a few more months will tell
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Re: Pelvic Varices

Postby beverley » Sat Mar 17, 2012 2:57 pm

I was just diagnosed through Potter MRI with Pelvic Varices (Pelvic Floor Congestion Syndrom). I also have some PNE symptoms that are not explained by Pelvic Varices. Does anyone who has posted in this section have any updates? I find the case study listed below interesting.

It appears that the varices could compress/irritate the Pudendal nerve and cause PNE symptons -- could this be seen in an MRI??

Is there any other treatment for Pelvic Varices other than surgery??
prolonged sitting summer -- Vulvar Burning, Vulvadynia, Urinary Frequency, Lower Back Pain, Numbness in Foot, Pain when sitting, Hip Pain
1/12 90% Better after Pelvic Floor PT and 10 mg of Elavil
3/12 Potter MRI
4/12 MRI showed Labral Tears in both hips
4/12 Hip Injection with Dr Jordon -- some improvement
7/12 FAI and Labral repair Hip Surgery, Dr Coleman, HSS, 10/12-3/13 99% better!
3/13 Flared - present,
7/14 Ilioinguinal nerve block positive
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Re: Pelvic Varices

Postby rick » Sat Mar 17, 2012 3:29 pm

Beverly,

Embolization by an interventional radiologist or a vascular surgeon is a
common procedure to deal with pelvic varices. Especially for a woman.

Take care.

Rick
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Re: Pelvic Varices

Postby flyer28 » Tue Jun 12, 2012 2:02 pm

I have also a large varix in the level of Alcock canal, seen on MRI.
Have bilateral penile pain and the focus of the pain is at the base of the penis, or slightly behind the penis.
My problems point out more to some dorsal nerve problem. I asked dr. Beco about pelivic varixes and he said that they are seldom the underlying problem.
In addition, dr. Aszmann has seen my MRI and stated that my Alcocks are OK, the problem seems to be more distal.
But my history points out to the hypothesis that venous system is somehow included - no sitting pain, but pain is worse after long standing, pain appeared initially after prolonged sex, pain is rather dull (sometimes burning), enlarged dorsal penile vein which increased day after my problems appeared back in 2009.
I still think that venous system is somehow playing its role in my problems, maybe pressing on dorsal nerves etc..
I am scheduled for 19th June for bilateal pudendal block at dr. Aszmann, I hope that this will help diagnostically. This might be break through in my case.
Matt
summer 2009 - episodic pain in genital area, mainly after sex, then also after any other physical labour
early 2010- major flare-up, lasting 3 months, later almost complete resulion of pain
late 2010 - chronification of pain
february 2011 - ESCW wave. major flare-up of debilitating pain, lasting 5 months
february 2012 - diagnosed CPPS with irritation of pudendal nerve, hypogastric plexus block
june 2012 - dorsal nerve block made by prof. Aszmann, no relief
november 2012 - worsening of pain
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Re: Pelvic Varices

Postby Violet M » Wed Jun 13, 2012 1:00 am

Good luck with your block, Matt. Hope it goes well for you. ;)

Violet
PNE since 2002. Started from weightlifting. PNE surgery from Dr. Bautrant, Oct 2004. Pain now is usually a 0 and I can sit for hours on certain chairs. No longer take medication for PNE. Can work full time and do "The Firm" exercise program. 99% cured from PGAD. PNE surgery was right for me but it might not be for you. Do your research.
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