Pelvic Congestion Syndrome: How to make the diagnosis?
Dilated pelvic veins are commonly seen on imaging in women with previous pregnancies, particularly on ultrasound, CT or MRI scans. However, these findings alone do not necessarily mean a woman has Pelvic Congestion Syndrome (PCS). The real challenge lies in distinguishing incidental dilated veins from clinically significant PCS that causes chronic pelvic pain.
So how do we make the correct diagnosis?
🔍 Recognising the Hallmarks of Pelvic Congestion Syndrome
A diagnosis of PCS should be based on clinical symptoms—with imaging used to support, not define, the condition. Below are the distinctive features that point towards a true diagnosis of PCS:
✅ 1. Chronic Pelvic Pain (CPP)
- Dull, aching, or dragging pain in the lower abdomen or pelvis
- Pain may be worse on the left side, or radiate to the lower back and thighs
- Not explained by other gynaecological conditions like endometriosis or adenomyosis
✅ 2. Pain Exacerbated by Venous Congestion
- Pain worsens after standing, walking, or sitting for long periods
- Typically worse at the end of the day, relieved by lying down or elevating the legs
- The pain is usually not the first thing in the morning.
- May worsen pre-menstrually or during menstruation
- These patterns can overlap with adenomyosis (heavy painful periods) or endometriosis—clinical judgement is key.
✅ 3. Pain with sex
- Often deep and dull during intercourse
- Pain after sex is typical, sometimes lasting several hours
✅ 4. Associated Symptoms That Raise Suspicion
- Visible varicose veins in the:
- Vulva
- Perineum or buttocks
- Upper inner or posterior thighs
- Bladder symptoms due to venous congestion of the bladder wall:
- Frequency, urgency, discomfort when the bladder is full
- UTI-like symptoms with negative cultures and no response to antibiotics
✅ 5. Typical Patient Profile
- Women aged 25–45, usually with two or more pregnancies
- But can affect any age group, with or without prior pregnancies
- Symptoms tend to worsen over time
- Many have been misdiagnosed as having psychological issues, IBS, chronic cystitis, or simply “unexplained” pelvic pain
🧪 Imaging Is Supportive—Not Definitive
While dilated ovarian or pelvic veins may show up on CT, MRI, or ultrasound, this finding is not diagnostic on its own. Many asymptomatic women have dilated veins. The diagnosis of PCS should be made clinically, using imaging to confirm suspicion—not to define the condition.
If the clinical suspicion is strong, a catheter venogram can confirm venous reflux and embolisaton could be performed at the same setting.
Learn more about venogram and venous embolisation treatment for PCS: https://www.sydneyfibroidclinic.com.au/pelvic-congestion/pelvic-congestion-treatment/
📌 Key Takeaway
Pelvic Congestion Syndrome is a clinical diagnosis.
The presence of pelvic varicose veins on imaging only becomes relevant when paired with the right constellation of symptoms. Relying on imaging alone can lead to overdiagnosis or misdiagnosis, while missing the opportunity to help those truly suffering from PCS.
For those with true PCS, venous embolisation is a definitive treatment.
Find out more about PCS treatment: https://www.sydneyfibroidclinic.com.au/pelvic-congestion/pelvic-congestion-treatment/