Pelvic vein conditions

In this episode of PodMD, Interventional Radiologist and Endovascular specialist Dr Jane Li will be discussing the topic of pelvic vein conditions. We discuss the causes of internal vein conditions, the complications if left untreated, how patients get assessed, the treatment options available and more.


  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Jane Li

    Dr Jane Li is an Interventional Radiologist and Endovascular specialist with over 15 years of experience. Dr Li completed her advanced surgical training in Sydney and her fellowship in London, where she focused on the treatment of venous and arterial disease, cancer, fibroids and complex liver conditions.
    She is one of very few Australians to have been awarded the European Board of Interventional Radiology, which recognises advanced experience, knowledge and skills in Interventional Radiology on an international level.

    Today, we’ll be discussing the topic of pelvic vein conditions.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Jane, thanks for talking with us on PodMD today.

    Jane : Thank you for having me.

    Question 1
    The topic of today’s discussion is pelvic vein conditions. Jane, can you first give us a brief overview of common pelvic vein conditions?

    Jane: Yes, thank you. The two main pelvic vein conditions we see and treat as interventional radiologists are pelvic congestion syndrome in females and varicose seals in males. These two conditions have similar underlying pathologies. They are both caused by. Refluxing or incompetent, the Natal veins being the ovarian vein and the testicular vein.

    To put it in simple terms, it’s like having varicose veins internally in our female patients. They can have refluxing ovarian veins or pelvic veins leading to enlarged para neutral and veins often located in the central pelvis and sometimes. They can be connected to the vulvar veins and also the leg varicose veins. In nail male patients that get dilated varicose veins in the scrotum from reverse blood flow and stagnation of blood in the testicular veins. It occurs in 15 to 20. Percent of all males.

    Question 2
    What do patients commonly present with in these vein conditions?

    Jane: Let’s firstly cover ovarian and pelvic vein congestion syndrome. It’s a syndrome because the patient can experience a number of symptoms, including back pain, lower abdominal pain or dragging sensation, radiating pain or heaviness to the ***** region. Pelvic pain congestion syndrome can cause irritable bowel symptoms and sometimes worse than blood incontinence.

    They may be associated with visible varicose veins in the vulvar vagina, inner thigh or the buttock region. And often the the female patient can present with heavy periods or even anaemia after the period. Now moving on to varicose sales, male patients get. A doll or dragging pain in the scrub. Words when they’re sitting or putting pressure in the area. They sometimes describe a scrotal mass or swelling, which can be quite alarming and definitely need further investigation. I had a patient who was a policeman who rides horses in fact, and every time he rode a horse he was getting heat. Sensation and more intense pain in the. Undercarriage, as he described it.

    Question 3
    What causes these internal vein conditions?

    Jane: The cause of the dilate of ovarian or pelvic veins in pelvic congestion syndrome is poorly understood. It’s commonly occurring in young women and usually in women who have had at least two or three pregnancies. During the pregnancy, the ovarian vein can be compressed by the enlarging womb, or enlarged and enlarged because of the increased blood flow.

    This is thought to affect the valves in the vein causing them to stop working or allowing blood to flow in the backward direction. Other causes include hormonal stimulation and polycystic ovaries. A congenital absence of valves may be a contributing factor. Less common is central vein obstruction causing a backward pressure on the veins. Similarly, the cause of dilated testicular vein and varicose seals in men is largely unknown. We think there could be a genetic predisposition to leaky valves being the primary contributing factor.

    Again, rarer causes include deep vein thrombosis in the renal vein, for example. Compression of the vein between their aorta and mesenteric artery, which is called The Nutcracker syndrome. Renal avian malformations or a thrombosis of the pampiniform plexus. Tobacco smoking has also been linked to this condition.

    Question 4
    Are there any serious complications if they are untreated?

    Jane: Yes, in females popins disease. Can affect their sexual function due to discomfort in the pelvis or their perineal region. They can experience mineralogic, as we mentioned during menstrual cycles with heavy bleeding or prolonged bleeding. Sometimes resulting in iron deficiency and anaemia. In male patients, varicose seal can give abnormal signal analysis.

    A low sperm count or decrease sperm motility. Presenting as self fertility, infertility clinically. In the worst scenario, they could also get testicular atrophy. Interventional radiologists are often refer these patients from urologists for subfertility. The excessive heat and hydrostatic pressure causes injury and stress. On the sperm. Hypoxia increase adrenal steroid production, probably play a role. It is thought that the larger varicose seals can eventually cause the testis to fail, and there’s a reduction in testosterone levels as well.

    Question 5
    How do patients get assessed?

    Jane: The main assessment of either pelvic venous congestion syndrome and varicose seal is by ultrasound. The dilated ovarian vein is harder to visualise because it is deeply located in the abdomen and can be very hard to trace for the sonographer, the right and the left are varying veins. Going very differently into the inferior vena cava on the right and renal vein on the left.

    Therefore a special vascular ultrasound would be required to look at these veins and assess them. Properly for reflux. A vein greater than six millimetre is likely to be abnormal and have reverse flow, confirming the presence of pelvic congestion. Importantly though, a reflecting, varying vein does not always give symptoms. And we can’t call this a syndrome unless patient did describe chronic symptoms that we mentioned before. In varicose pills, it’s a little bit different.

    They are a bit more superficial in men and therefore are easier to access and assess with scrotal ultrasounds. The dilated, pampiniform plexus veins. Are positive for diagnosis of reflux if they are greater than 3 millimetre in diameter. The varicose seals can be graded. Into small, moderate or large. Or that can be graded. By their degree of reflux. Special venogram MRI and CT are also very helpful when identifying the dilated veins and also help us work out anatomy to plan our treatment.

    The most accurate test is angiography angiographic testing. Which is an endovascular technique. Performed by interventional radiologists and endovascular specialists. Testing each of the possible veins involved by injecting contrast directly into the vein and seeing how the blood flows in the vein under X-rays.

    Question 6
    What treatments are available for them?

    Jane: There are surgical options of laparoscopic abdominal surgery. Or from an. Angular approach to tie off the dilated veins. In these cases, the various difference and testicular artery have to be avoided for a safe approach. And there are obvious side effects such as bleeding, scarring and post operative pain. In interventional radiology, we offer an endovascular approach using angiography. The procedure is merely invasive and involves a very tiny incision in the skin to get into.

    The jugular, femoral vein and we can then get inside the central veins to assess the vernal veins. With the fine catheter, we can gain access into the ovarian or testicular vein. And if there is reflux on X-rays? We can proceed to close off these fans. What we call embolization with metallic coils. We very carefully insert these coils and sometimes also use Spiro therapy at the same time to make sure we get a reliable closure. Embolization of varying veins and varicose seals. Have an 89% success rate.

    The pelvic veins in females have a very complex network and there are many variations in anatomy. The same goes for testicular veins in males. It is therefore best performed by an experienced specialist who have good knowledge of anatomy and the skill to find the culp of veins and avoid a failure in embolization. So in practical practise, what I often do is perform a very thorough pelvic and geography diagnostic study before committing to blocking off any veins. The complication rate with this endovascular technique. Is very low.

    Patients can get a dull ache or pain for one to two weeks. Irregular periods for the first few cycles, but hopefully an overall improvement of their symptoms. Complications such as coral migration and bleeding risk are very, very rare. Patients can usually hit home on the same day and return to normal activities within the week.

    Question 7
    When should a GP refer?

    Jane: We found these days many patients are actually very well educated on medical conditions they have with a wealth of information available on the Internet. So it wouldn’t. Be surprising to find that patients approach the GP in practise to ask for a referral or ask about specific procedure. Therefore, it is a harder job, probably for GP’s, to know the different conditions and treatment options out there to give them. The right advice?

    There is very good and important importantly and very reliable. Availability of information on the Australian Society of Interventional Radiology websites. By typing in the keyword Ursa or IRSA. And it will provide very good information on these new endovascular techniques. There is also easy to understand information for patients to read. Female patients with pelvic vein symptoms such as. Abdominal pain or menorrhagia and any relationship also with external varicose veins.

    For example, *****, buttock or leg varicose veins will be suitable for an assessment defying interventional radiologist. Male patients with scrotal pain or swelling should get an ultrasound first. And the diagnosis of varicose seal is made on ultrasound. Then they should then be referred to. A specialist for assessment and potential embolization procedure if the GPU referer is unsure, then many of us have direct enquiry emails on their websites and will be very happy to discuss these conditions with them.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on pelvic vein conditions?

    Jane: The first take home message would be both male and female. Patients can get internal varicose veins. They can be connected to the external varicose veins, or sometimes more concerning. Are manifestations of deep vein issues. Secondly, the two conditions are very similar in pathophysiology due to reverse flow in the gonadal veins or the pelvic vein. Clinically, representing in very different ways. And thirdly, there is merely invasive in the vascular treatments now available performed by interventional radiologists that can give patients with symptomatic relief.

    Thanks for your time and the insights you’ve provided.

    Jane: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.