Pelvic congestion syndrome and May-Thurner syndrome as causes for chronic pelvic pain syndrome: neuropelveological diagnosis and corresponding therapeutic options

Abstract

Objective: To report on diagnosis and management of pelvic congestion including the May-Thurner syndrome (MTS) as potential etiologies for intractable pelvic neuropathic pain.

Design: Retrospective study of women presented with intractable pelvic neuropathic pain, who had left sided venous uterine plexus above 6mm with reversed and slow flow on Doppler, with dilated arcuate veins passing through the uterine muscle. Those with suspicion of MTS underwent further radiological investigations and if applicable, endovascular interventions.

Setting: Tertiary referral unit specialized in advanced gynaecological surgery and neuropelveology.

Intervention: 61 consecutive patients were included. 14 with visceral pain presumed to be caused by Pelvic Congestion Syndrome were treated by ovarian vein embolization. An improvement of pain was observed in all patients - mean pain reduction of 3.93 points, from 7.21 (±1.42; 4-10) to 3.28 pts (±1.54; 1-6) over 6 months (p<0.01). 47 presented with pelvic somatic neuropathic pain; 19 underwent endovascular intervention (angioplasty, stenting) and finally all of them a laparoscopic exploration/decompression of the sacral plexus and the endopelvic portion of the pudendal nerves, with an overall VAS reduction from 8.56 (±1.1712;7-10) to 2.63 (±1.53; 0-6) at one-year-follow-up (p<0.01).

Conclusion: Laparoscopic exploration/decompression of the nerves seems to be effective in a carefully selected group of patients. Endovascular interventions for pelvic somatic neuropathies may not be an effective treatment. We recommend that Doppler studies of the uterine vessels are performed as an extension to gynaecological examination in women with intractable pelvic pain.

Conflict of interest statement

Conflict of interest: None.

Figures

Figure 1

— Left sided dilated uterine vein >6mm in diameter with dilated arcuate veins passing through the uterine muscle.

Figure 2

— Stenosis of the left common iliac vein.

Figure 3

— Confirmation by MIR & Venography.

Figure 3

— Laparoscopic exploration/decompression of the sacral plexus by an enlarge and atypical superior gluteal vein (Left: before the decompression – Right: after the decompression). ON: obturator nerve – SGV: superior gluteal vein – LST: lumbosacral trunk – PN: pudendal nerve – SN: sciatic nerve – GSF: greater sciatic foramen – S: sacral nerve root.

Table I

— Decision flow chart.

Figure 5

— volution of VAS of patients after LSC nerves decompression in patients secondary to endovascular intervention by significant MTS (n=19). Blue lines: patients with pain decreased >50% (n=16) Red lines: patients with pain decreased 30-50% (n=3) Black line: mean value.

Figure 6

— Evolution of patients who did not required any endovascular treatment and with a VAS reduction >50% after LSC nerves decompression (n=29).

Figure 7

— Evolution of patients who did not require any endovascular treatment and with a VAS reduction 30-50% (green lines – n=3) or