Pelvic congestion syndrome and May-Thurner syndrome as causes for chronic pelvic pain syndrome: neuropelveological diagnosis and corresponding therapeutic options
M Possover, S Khazali, A Fazel, M Possover, S Khazali, A Fazel
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
References
- Barnes RW, Fleisher HL, Redman JF, et al. “Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): repair by a new stenting procedure”. Journal of Vascular Surgery. 1988;8:415–421.
- Butros SR, Liu R, Oliveira GR, et al. Venous compression syndromes: clinical features, imaging findings and management. Br J Radiol. 2013;86:20130284.
- García-Gimeno M, Rodríguez-Camarero S, Tagarro-Villalba S, et al. Duplex mapping of 2036 primary varicose veins. J Vasc Surg. 2009;49:681–689.
- Greiner M. Syndrome de congestion pelvienne: diagnostic et traitement. Phlébologie. 2005;58:293–298.
- Greiner M, Faye N, Thouveny F, et al. Traitement endovasculaire par embolisation de l’insuffisance veineuse pelvienne chronique In: Greiner Milka, ed Thérapeutique Endovasculaire des Pathologies Veineuses Springer-Verlag. 2012. 236 264
- Kibbe MR, Ujiki M, Goodwin AL, et al. Iliac vein compression in an asymptomatic patient population. J Vasc Surg. 2004;39:937–943.
- Lechter A, Lopez G, Martinez C, et al. Anatomy of the gonadal veins: a reappraisal. Surgery. 1991;109:735–739.
- Lemasle P, Uhl JF, Lefebvre-Vilardebo M, et al. Veine du nerf sciatique et maladie variqueuse. Aspects écho-anatomiques et hémodynamiques. Phlébologie. 2001;54:219–228.
- Oteki T, Nagase S, Hirayama A, et al. “Nutcracker syndrome associated with severe anemia and mild proteinuria”. Clinical Nephrology. 2004;62(1):62–65.
- Possover M. New surgical evolutions in management of sacral radiculopathies. Surg Technol Int. 2010;19:123–128.
- Possover M. Sacral radiculopathies by vascular entrapment/irritation” - an unrecognized but frequent cause for unexplained intractable “pelvic pain syndrome”. Gynecology & Obstetrics. 2011;4:35–38.
- Possover M, Forman A. Neuropelveological assessment of pelvic neuropathic pain. Gynecol Surg. 2014;11:139–144.
- Possover M, Forman A. Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression. Pain Physician. 2015;18:E1139–E1143.
- Possover M. Neuropelveology – lastest developments in Pelvic Neurofunctional Surgery ISBN: 97895244533-0-8 2015. 26
- Sugimoto I, Takashi O, Ishibashi H, et al. “Left Renal Vein Entrapment Syndrome (Nutcracker Syndrome) treated with Left Renal Vein Transposition”. JNP J Vasc Surg. 2001;10:503–507.
- White JM, Comerota AJ. Venous Compression Syndromes. Vasc Endovasc Surg. 2017;51:155–168.
Source: PubMed