The concurrent presence of venous varices with pelvic pain in premenopausal women does not always mean that they are causally related. Even in asymptomatic females, the dilation and incompetency of pelvic veins are common findings. This creates a challenge in identifying which patients have chronic pelvic pain due to pelvic congestion syndrome. 

The pain associated with PCS presents as a dull ache or a sensation of heaviness in the pelvis. It can last 3 to 6 months and can be unilateral or bilateral. However, pain can switch from one side to the other. Any factor increasing the abdominal pressure (walking, postural changes, lifting, and longtime standing position) can increase the intensity of pain. It is often exacerbated before or during the menstrual periods. The intensity of pain worsens with each subsequent pregnancy, and during or after sexual intercourse. the time of the day also affects the intensity with pain being worse at the end of the day.[13]

If the findings of characteristic pelvic pain are present, physical examination can help in formulating the final diagnosis. The uterine tenderness, ovarian tenderness, and cervical motion tenderness on direct palpation during bimanual examination in a patient presenting with a complaint of chronic pelvic pain support the diagnosis of PCS. 

In a study with 57 females suffering from pelvic pain, the combination of a history of postcoital pain with tenderness over adnexa during physical examination came out to be 77% specific and nearly 94% sensitive for differentiating pelvic congestion syndrome from other pathologies of pelvic origin.[6]

The presence of characteristic pelvic venous changes on imaging supports the diagnosis but is not necessary for forming the final diagnosis. Dilated ovarian veins with incompetency of the valves is also a common finding in asymptomatic women.[14] 

For patients with PCS, in whom an intervention is being planned, require evaluation for pelvic venous reflux with ultrasound, retrograde internal iliac or ovarian venography, computed tomography (CT), or magnetic resonance (MR) imaging.[15]

Ultrasound:

The first line imaging study for pelvic congestion syndrome is pelvic ultrasound. Ultrasound helps rule out the presence of pelvic masses or uterine problems as the underlying cause for the pelvic pain. Using color-Doppler and conventional B-mode of ultrasound, the pelvic anatomy, ovarian changes, uterine enlargement, and dilated uterine and ovarian veins can be evaluated.[16] 

Retrograde flow of blood with an increase in the size of the left ovarian vein and a decrease in velocity of the blood flow can be observed using ultrasonography. Enlarged, tortuous pelvic venous channels can be noted. The incompetency of valves in the pelvic varicose veins can be noted using Valsalva's maneuver. These varicoceles will show variable duplex waveform on such maneuvers. Polycystic changes of the ovary are also seen in patients with pelvic congestion syndrome.[3][6]

Computed tomography and magnetic resonance: 

The anatomical details of the pelvic vasculature along with the tissue of the pelvic cavity can be easily visualized with computed tomography and magnetic resonance imaging. Since CT utilizes radiation, it is not recommended in premenopausal women.[17]

For diagnosing pelvic vasculature varices, magnetic resonance venography is a good modality. It is a noninvasive imaging technique with low risk. But the specificity of this imaging modality for venous pathologies is low since the patient is in a supine position for this examination.[18]

The direction and velocity of flow in different vascular channels can be assessed with phase-contrast velocity mapping, which is an MRI based technique. This technique can be used to evaluate pelvic veins.[19] 

Venography: 

The gold standard for diagnosing pelvic congestion of the vasculature is ovarian and iliac catheter venography. Ovarian veins are catheterized by approaching via percutaneous jugular and femoral pathway. The distension of the venous channels is better assessed when venogram is done during Valsalva. Venographic diagnostic findings of PCS that can be seen include incompetent pelvic veins (with diameter more than 5-10mm), and congestion of flow in venous channels of ovarian, pelvic, vulvovaginal, and thigh veins. Venous reflux in ovarian veins can also be noted.[17]  

Laparoscopy: 

Chronic pelvic pain is a major cause of gynecologic diagnostic laparoscopies. According to certain reports, more than 40 percent of such laparoscopic procedures are due to chronic pelvic pain.[20] The rate for the occurrence of pathological findings identified on laparoscopies on women with chronic pelvic pain range between 35% and 83%. In 20% of these cases, pelvic congestion is also identified.[21]

Medical management should be the first-line treatment for PCS. This is due to decreased complications of medical management as compared to invasive procedures. Gonadotropin-releasing hormone agonists, danazol, combined oral contraceptives, progestins, phlebotonics, and non-steroidal anti-inflammatory drugs are a few treatment options that have shown effective management for the pain in PCS.[22] Etonogestrel implant, goserelin, and medroxyprogesterone acetate have also been successful in alleviating the pain associated with PCS.[3] Improved pain relief is observed when medroxyprogesterone is given along with psychotherapy.[23] Goserelin, a GnRH agonist, has better results in controlling the pain as compared to medroxyprogesterone acetate, but it cannot be continued beyond 1 year due to it being a GnRH agonist.[3] 

Ligation of incompetent ovarian veins can lead to favorable results. In nearly 75% of women, ligation of the incompetent ovarian or pelvic vessels leads to the resolution of the symptoms. Gynecologists have used bilateral salpingo-oophorectomy and hysterectomy as a treatment for pelvic congestion syndrome, but the results were not favorable.[15] 

The ablation of incompetent veins can also be achieved by endovascular procedures using a minimally invasive approach. These procedures can be performed in an outpatient setting leading to comparatively quick recovery and fewer complications.[24] Different agents like platinum embolization coils, glue, foam, or liquid sclerosants can be used for causing endothelial damage in the incompetent vessels.[25]

The list of the differential diagnoses for pelvic congestion syndrome is vast. It includes diseases of the urinary tract, gastrointestinal tract, musculoskeletal disorders, disorders of neurological origin, gynecological problems, and mental health disorders. Painful bladder syndrome, pelvic inflammatory disease, interstitial cystitis, endometriosis, pelvic neuralgia, irritable bowel syndrome, myofascial pain, and pelvic floor myalgia are the common causes of chronic pelvic pain. Formulating the accurate diagnosis of the underlying cause of chronic pelvic pain is difficult even with the use of laparoscopic and diagnostic radiological tests.[1][2]

The women afflicted with pelvic congestion syndrome report resolution of symptoms in nearly 68.2%-100% of the cases with treatment. However, with pelvic embolization, 6% to 31.8% have reported no significant relief of pain associated with pelvic congestion syndrome.[26]

With surgical treatments for pelvic congestion syndrome, there is an increased rate of recurrent pelvic pain (20%) or residual pain (33%). Moreover, there is often aesthetic damage and longer hospitalizations with surgical treatments.[27] The loss of gonadal function leading to the need for hormonal replacement is also an important complication of ovarian vein ligation and oophorectomy.[28]

Pelvic congestion syndrome is prevalent in almost 2.1% to 24% of the women in the age group of 18-50 years. This shows the importance of educating patients with PCS. They should be educated regarding treatment adherence and to note any relation between their symptoms and their menstrual cycle. With bilateral oophorectomy, there is often a need for hormonal replacement. The patients should also be educated about these complications.[29]

Chronic pelvic pain accounts for almost 10%-20% of gynecologic consultations. Out of these, nearly 40% are referred to specialists for evaluation. The diagnosis of pelvic congestion syndrome requires a high clinical suspicion on the clinician’s part. After diagnosis, medical or surgical management may be deemed necessary. The radiological approach for embolization is also considered. Therefore, the coordination between an interprofessional team that includes primary clinicians, gynecologists, and the interventional radiologists is an important aspect of maintaining good outcomes of the management of patients with pelvic congestion syndrome.[30]