Pelvic Congestion Syndrome (PCS) Imaging

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Chronic pelvic pain · venous insufficiency
   Chronic pelvic pain — pelvic venous insufficiency signs? (PCS/pelvic venous insufficiency = ovarian/pelvic vein reflux → pelvic varices, chronic pelvic pain (worse with prolonged standing/after intercourse; dull pain/dysuria/dyspareunia, vulvar/leg varices). TVUS + Doppler preferred (dynamic): ovarian vein >6 mm, parametrial/periovarian veins >4 mm, reflux/slow flow ≤3 cm/s, dilated arcuate veins crossing the myometrium; worse with Valsalva. Note supine position underplays varices and risks missing them; a normal scan does not exclude it; many with varices are asymptomatic.)
   • Criteria met + symptoms (planning intervention) → Criteria met + symptoms · vein embolization
   • Suspected secondary obstruction (nutcracker/May-Thurner/mass) → Suspected secondary obstruction · treat the cause first
   • Imaging suspicious but uncertain / symptoms don't fit → Uncertain · MRV/CT further
2. [End] Uncertain · MRV/CT further
   Imaging suspicious but uncertain (or varices not seen supine, symptoms don't fit): MRI (including time-resolved MRV) or CT for further assessment (Coakley: ≥4 tortuous parametrial veins on the same side, ≥1 >4 mm, or ovarian vein >8 mm); venography is the gold standard, confirming when non-invasive is uncertain; exclude other causes of pelvic pain.
3. [End] Suspected secondary obstruction · treat the cause first
   Suspected secondary obstructive cause (left renal vein compression nutcracker, iliac vein May-Thurner, mass compression): assess and treat the obstructive cause first; treating varices/reflux alone without relieving the obstruction worsens venous hypertension; CT/MRV/venography to assess.
4. [End] Criteria met + symptoms · vein embolization
   Criteria met + symptoms (US: ovarian vein >6 mm, parametrial/periovarian veins >4 mm, reflux/slow flow ≤3 cm/s, dilated arcuate veins crossing the myometrium; worse with Valsalva): pelvic/ovarian vein embolization is the first-line definitive treatment (better than medical/surgery); exclude secondary obstruction first.

Source guidelines & references

• Pelvic venous insufficiency imaging diagnosis and treatment (AJR 2015; RadioGraphics 2019) · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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