Guideline sources The following summarized guidelines for the evaluation and management of pelvic congestion syndrome are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2022), the American College of Radiology (ACR 2021), and the Society for Vascular Surgery (SVS/AVF 2011). 1 2 3 Guidelines 1. Screening and diagnosis Differential diagnosis: exclude other causes of pain in female patients with pelvic pain and a clinical suspicion of pelvic venous disorders. B 2. Diagnostic investigations Diagnostic imaging: As per ESVS 2022 guidelines, obtain specific duplex ultrasound assessment of pelvic escape points in patients presenting with symptomatic varicose veins where there may be a pelvic origin. B Show 2 more As per ACR 2021 guidelines, do not make the diagnosis of pelvic congestion syndrome based on CT or MRI findings, unless the patient meets clinical and imaging criteria. D As per SVS 2011 guidelines: https://web.pathway.md/diseases/reci9jpco3hjNWM7K 1/3 6/29/23, 10:58 PM Pelvic congestion syndrome Pathway As per SVS 2011 guidelines: Obtain noninvasive imaging with transabdominal and/or transvaginal ultrasound, CT, or MRV in selected patients with symptoms of pelvic congestion syndrome or symptomatic varices in the distribution of the pubis, labia, perineum, or buttocks. B Obtain retrograde ovarian and internal iliac venography in patients with pelvic venous disease, confirmed or suspected by noninvasive imaging studies, when an intervention is planned. B 3. Therapeutic procedures Local procedures: As per ESVS 2022 guidelines, consider offering local procedures for varicose veins and related pelvic escape points as initial therapeutic approach in patients with varicose veins of pelvic origin without pelvic symptoms requiring treatment. C As per SVS 2011 guidelines, consider offering plugs or transcatheter sclerotherapy, alone or together with coil embolization, in patients with pelvic congestion syndrome and pelvic varices. C Pelvic vein embolization: As per ESVS 2022 guidelines: Do not perform pelvic vein embolization as initial treatment in patients with varicose veins of pelvic origin without pelvic symptoms. D Consider performing pelvic vein embolization to reduce symptoms in patients with varicose veins of pelvic origin with pelvic symptoms requiring treatment. C As per SVS 2011 guidelines, consider performing coil embolization, alone or in combination with plugs or transcatheter sclerotherapy, in patients with pelvic congestion syndrome and pelvic varices. C 4. Surgical interventions Indications for surgery: consider performing surgical ligation and excision of ovarian veins to treat reflux, if less invasive treatment is not available or has failed. C Clinical findings Symptoms Past obstetric history Abdominal pain Multiparity Diarrhea Dyspareunia Low back pain Pelvic pain Urinary frequency Urinary incontinence https://web.pathway.md/diseases/reci9jpco3hjNWM7K 2/3 6/29/23, 10:58 PM Pelvic congestion syndrome Pathway References 1. Peter Gloviczki, Anthony J Comerota, Michael C Dalsing et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53 5 Suppl):2S 48S. Open 2. Marianne G De Maeseneer, Stavros K Kakkos, Thomas Aherne et al. Editor's Choice European Society for Vascular Surgery ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022 Feb;63 2 184 267. Open 3. American College of Radiology. Choosing Wisely: Recommendations of the American College of Radiology. Choosing Wisely. 2021. Open https://web.pathway.md/diseases/reci9jpco3hjNWM7K 3/3