Chronic Pelvic Pain (CPP) is defined as persistent, noncyclic pain (not affected by menstrual cycle) in the pelvic region that lasts for more than 6 months. CPP affects an estimated 15 to 20 percent of women, ages 18 to 50, and it is likely that the true incidence is even higher. CPP can be debilitating! It can disrupt work, physical activity, sexual relations, sleep or family life. It can also affect a woman’s mental and physical health. Many women experience CPP symptoms for a year or more before seeking treatment.

Generally, a woman will see her primary care provider as the first step in getting evaluated for CPP. Statisically, the most common causes of gynecologic CPP include endometriosis, adenomyosis, and uterine fibroids. It is important that women get evaluated for these conditions as they can often be treated. Non-gynecologic causes of CPP may include irritable bowel syndrome (IBS), interstitial cystitis (IC), pelvic floor dysfunction and numerous other conditions.

However, what is often not considered by many primary care providers are the vascular causes of CPP discussed below.

1. Pelvic Venous Insufficiency (PVI) is one of the most common vascular causes of CPP. Previously referred to as pelvic congestion syndrome (PCS), PVI affects multiparous (more than 1 pregnancy) women of childbearing age. In rare instances, it can be seen in nulliparous (never been pregnant) and elderly women. PVI can cause CPP in addition to pain with intercourse (dyspareunia), increased urinary frequency, constipation, heavy menstrual bleeding, and vaginal/thigh varicosities. PVI is due to blood refluxing (going backwards) down the ovarian veins resulting in pooling of blood within the pelvis. Add in the effects of gravity combined with prolonged sitting or standing and it’s the perfect recipe for CPP symptoms to develop.

PVI is often treated with ovarian vein embolization (OVE), a minimally invasive same-day procedure in which the ovarian vein is closed off with metallic coils to prevent blood from refluxing down the vein and pooling in the pelvis. While OVE has been shown to be successful in many women, the procedure is often not covered by insurance due to the lack of large clinical trials. Moreover, there is a belief by many insurance companies and ob-gyns that PVI does not exist which often leads to a delay in dignosis and treatment.  PVI is generally diagnosed and treated by a vascular specialist such as an interventional radiologist (IR).

2. May Thurner Syndrome (MTS) is an anatomic variant in which the right common iliac artery compresses the left common iliac vein against the bone of the spine. Depending on the amount of compression, blood flow in the left common iliac vein will slow down or even stop, leading to a blood clot or deep vein thrombosis (DVT). Other conditions associated with MTS include left leg swelling that is mistaken for lymphedema, chronic pelvic pain or pelvic venous insufficiency (i.e. pelvic congestion syndrome), and low back pain. MTS is treated by placing a permanent stent in the iliac vein in the pelvis to prevent the iliac artery from compressing it. Determining whether MTS or PVI is the cause of chronic pelvic pain can be challening and therefore it is important to see a vascular specialist well versed in both of these conditions.

3. Nutcracker Syndrome (NCS) is another cause of CPP caused by compression of the left renal vein as it courses between the superior mesenteric artery (SMA) and the aorta (the major artery of the body). In addition to CPP, NCS is often accommpanied by left flank pain, hematuria (blood in the urine) and proteinuria (protein in the urine). Other symptoms seen with PVI can be seen with NCS. The treatment of NCS is more controversial than PVI or MTS. Treatment can include stenting of the left renal vein or transposition of the left renal vein. In some cases, major surgery such as auto transplant is performed in which the kidney is removed from the abdomen and placed in the pelvis. NCS can often require a multidisciplinary approach from surgeons and interventional radiologists.

Left renal vein stent                                                                                          Left renal vein transposition

4. Post Thrombotic Syndrome (PTS) also referred to as post phlebitic syndrome is the long-term complication of blood clots or deep vein thrombosis (DVT). Patients with DVT involving the pelvic and leg veins have the highest risk of over 50% of developing PTS within 1-2 yrs of their DVT. PTS symptoms can include chronic leg pain and swelling, skin discoloration, varicose veins, venous ulcers, and chronic pelvic pain. Often when the iliac vein is completely blocked from DVT, this can be due to unrecognized May Thurner Syndrome and result in the development of large pelvic collaterals which leads to CPP. No matter how long one has been affected by PTS, in specialized centers PTS can be treated, leading to a significant improvement in leg and CPP symptoms.

5. Chronic Venous Insufficiency (CVI) or superficial venous insufficiency is due to blood refluxing or going backwards in the superficial veins of the leg. CVI is the underlying cause of symptoms such as leg heaviness/fatigue, ankle swelling, restless legs, night cramps/Charley horses, spider and varicose veins, skin discoloration, and venous ulcers. CVI affects 25% to 90% of the population in their lifetime and is one of the greatest epidemics in this country that goes undiagnosed. Because the superficial veins start in the groin, pain in the groin/hip can occur and often be confused as chronic pelvic pain. In rare cases, the refluxing veins may originate in the pelvis rather than the groin and cause CPP in addition to leg symptoms. CVI is initially managed with compression stockings, exercise, and weight loss. Treatments such as vein ablation or sclerotherapy have extremely high success rates and treatment is often covered by insurance.