Pelvic Congestion Syndrome: Often Undiagnosed and Misdiagnosed

Hello and welcome to the November 2021 edition of Vascular Disease Management. I have chosen to comment on the article by Dr. Naga Sai Shraven Turaga and colleagues, “Nutcracker Syndrome: A Rare Etiology of Pelvic Congestion Syndrome.” I have chosen to comment on this case report as it provides an excellent review of Nutcracker syndrome and the differential diagnosis of pelvic congestion syndrome. The article reviews appropriate diagnostic testing and therapeutic options, and it includes excellent images of the treatment administered in this case. This case report details the steps and tests required to first diagnose, then subsequently treat, pelvic congestion syndrome in general and Nutcracker syndrome specifically. As with most obstructive venous disorders, external duplex ultrasound, intravascular ultrasound, angiography, and stenting are instrumental in diagnosis and treatment.

I have decided to comment on this case as pelvic congestion syndrome is a relatively common disabling condition with multiple potential etiologies that is often undiagnosed or misdiagnosed. In my opinion, traditional general medicine and OB-GYN training programs have not emphasized the importance of this disorder and its profound medical and psychosocial consequences. In general, there is very little training emphasis on most venous disorders, even though they are common and associated with substantial patient discomfort and risk.

Patients with pelvic congestion syndrome have historically been treated with pain medicines (which only blunt the pain) or anxiolytic or antidepressant medicines (which afford no relief) rather than with interventional or surgical procedures that address the congestion and alleviate the source of discomfort. Failure to appropriately treat this syndrome results in pain, suffering, and the demise of many marriages and relationships.

Unfortunately, most patients with pelvic congestion syndrome do not have access to appropriate testing—even when clinicians suspect the diagnosis—as there is a shortage of skilled ultrasound technicians trained in transvaginal studies to facilitate the noninvasive diagnosis. Far too often, ultrasound studies return only with an interpretation of a clot or no clot, with no mention of insufficiency. There is also a shortage of interventionists properly trained in the treatment of this disorder.

Pelvic congestion syndrome is one of many disorders in which impaired venous drainage results in significant pathology. The disorders of venous drainage are, in general, underdiagnosed and misdiagnosed.

May-Thurner syndrome, perhaps the most common etiology of impaired venous drainage of the lower extremities other than thrombosis, is commonly treated with diuretics or antibiotics with the mistaken diagnoses of congestive heart failure or cellulitis, respectively. Failure to diagnose iliac vein compression, or obstructive webs in cases of extensive venous ulceration, may preclude effective healing of venous ulcers and result in recurrent bouts of ulceration following treatment where ulcers have been healed with conservative therapy. Clearly, any patient with recurrent lower extremity venous ulcers should be evaluated for evidence of impaired venous drainage.

Venous disorders are extremely common but unfortunately have not received appropriate attention, in my opinion. These disease states are, in general, more difficult to diagnose than arterial disorders, and there has been far less emphasis on educating healthcare providers in diagnostic and treatment options than these conditions deserve.

I firmly believe that with further education, not only will healthcare providers more accurately diagnose disorders of venous drainage, but improved diagnostic and therapeutic tools will be developed as well. Venous disorders are common, and these disorders must receive more attention than they have historically been afforded. We must appropriately train to more effectively treat venous pathology.