“An attractive option”

Prof. Mark S. Whiteley, a British vascular surgeon, has been researching venous disorders for more than 20 years, and Pelvic Congestion Syndrome (PCS) in particular. In 2019, together with Emma Budd, PhD, he received the Bauerfeind Phlebology Award (BPA) for his study project on the effects of compression therapy in patients with PCS.

life: Could you briefly explain Pelvic Congestion Syndrome (PCS) please? What are the causes?

Prof. Whiteley: : Pelvic Congestion Syndrome (PCS) or Pelvic Venous Disorders (PeVD), as it’s increasingly called in this field of research, can be easily described as “varicose veins of the pelvis”.
Our research has shown that the most common cause for this is venous reflux in the gonadal veins, i.e. the ovarian veins in women or testicular veins in men, as well as the internal iliac veins in the pelvis. This reflux usually develops when the venous valves become incompetent.
In a small percentage of patients, an obstruction of a vein can also prevent the blood from flowing back to the heart. Classic cases include the Nutcracker Syndrome where the left renal vein is trapped under the superior mesenteric artery, and the May-Thurner Syndrome where the left common iliac vein is trapped under the right common iliac artery. These arterial compression syndromes can cause an obstruction of the venous blood flow. The venous blood must then find an alternative route, and so dilates otherwise normal veins, which results in “varicose veins of the pelvis”. The consequence is the Pelvic Congestion Syndrome.
Many physicians look primarily for obstructions as the cause. However, our own research shows that obstruction accounts for only one to two percent of cases, while 98 percent are caused by reflux.

What symptoms do patients exhibit?

Prof. Whiteley: As with all conditions, we differentiate between symptoms that patients feel, such as draggingor pain in the pelvis, deep pain during or after intercourse, or hip pain, and signs that patients can see, such as varicose veins in different parts of the body. (See box on Page 25) The difficulty is that in every sixth woman with varicose veins in the legs, PCS is a causative factor, but these women do not mention typical PCS symptoms during the first examination. Many patients feel better after pelvic vein treatment, even though they were not aware that they were symptomatic before treatment. But many patients with leg varicose veins arising from the pelvis actually are asymptomatic from pelvic symptoms. Additionally, almost all pelvic symptoms can have other causes apart from PCS. That is why the symptoms specified indicate possible PCS but do not provide a certain diagnosis.

What examinations do you conduct to make a diagnosis?

Prof. Whiteley: Our published studies have shown that the only reliable “gold standard” for the diagnosis of PCS in women is a transvaginal duplex ultrasound of the veins following the Holdstock-Harrison Protocol, combined with a transabdominal examination for obstruction following the Holdstock-White Protocol. It’s particularly important that, according to the protocol, the patients are examined in a 45° head up position to allow for reflux in the veins, which can be visualised via duplex ultrasound.
An MRI (MRV) or CT scan, on the other hand, is ineffectual because varicose veins disappear when the patient is lyingflat, which is the case with these investigations. During laparoscopy, the affected veins can often not be seen because they are located deep in the pelvis under the peritoneum. Even venography, which is often seen as the gold standard, is non-physiological. The contrast agent has a different density than the blood and can only be seen where it was injected. The patients have to be moved into different positions to ensure reflux, and reflux at the bottom of the vein may not be recognizable if proximal valves prevent the contrast agent from getting into the area of the reflux.
Of course, it becomes very difficult if females are unable or unwilling to have the transvaginal venous duplex ultrasound, and in addition, this cannot be performed in males. Therefore, we are looking for a new gold standard for these patients.

How many people are affected by PCS?

Prof. Whiteley: Several publications indicate that about every third woman who visits her gynecologist because of chronic pain in the pelvis suffers from PCS. Unfortunately, most of these patients are incorrectly diagnosed with endometriosis, or they are told that nothing is wrong with them.
We also know that PCS is the cause for varicose veins in the legs of one in six women and one in 30 men. In addition, thousands of men are affected by varicocele every year. And about 50 percent of all adults suffer from hemorrhoids at some point in their lives. There are no reliable figures for impotence in men owing to varicose veins in the pelvis. This shows that a huge number of people of both sexes is affected by this problem, which still requires much more research.

How is PCS currently treated?

Prof. Whiteley: Many mild cases can be treated with simple analgesia or progesterone. Most women whose PCS symptoms are so severe that their daily lives and sex lives are affected, or where the signs, such as varicose veins in the pelvis or the legs, have their cause in the pelvis, have to undergo an embolization of the pelvic veins.
In the Whiteley Clinic, we have been carrying out this procedure for 20 years, and for the past five years, this has been a walk-in, walk-out local anesthetic procedure. A local anesthetic is given under the skin in the injection site in the right side of the neck. Then, with X-ray monitoring, we insert a catheter into the gonadal vein and/or the iliac vein. Foam sclerotherapy is used to close the veins near the sensitive organs in the pelvis and platinum coils are used to then close the veins above the foam and away from the sensitive organs. Six weeks after the procedure, a transvaginal ultrasound is carried out for all patients following the Holdstock-Harrison Protocol, to check that the treatment has been successful. We have published our long-term results showing this is both effective and long lasting.¹

Yet, you are currently preparing a study supported by the BPA on the effects of compression therapy in cases of PCS. What hypotheses have you put forward?

Prof. Whiteley: A research paper from Russia suggests that PCS symptoms can be alleviated by wearing compression pants. The theory behind it is that chronic pain connected with PCS is reduced by supporting the lower abdomen and the pelvis. If this turns out to be correct, it would be a cost-effective improvement of the symptoms.
The aim of this study is to show whether this kind of compression can achieve a relief in symptoms. Then we will compare these results with the relief in symptoms achieved with embolization.

How will the study be conducted?

Prof. Whiteley: : Patients who have been diagnosed with Pelvic Congestion Syndrome with 1A and 1B symptoms (see box on Page 25), and whose transvaginal duplex ultrasound of the veins following the Holdstock-Harrison Protocol was positive, will be invited to take part in the study.
Once the declaration of consent has been submitted, the participants will be asked to complete a list of symptoms. They will then receive compression therapy for three months, after which they will be asked about their symptoms again. Embolization of the pelvic veins will follow, and the symptoms will be recorded again.
In this way, we will be able to see the improvements brought about by each technique and compare the improvements from both techniques.

Why does compression therapy play an important role?

Prof. Whiteley: We have already conducted a study on compression of the thighs, the buttocks, and the lower abdomen to reduce cellulite. There patients reported that they felt good support in the lower abdomen.
The proposal is that we can mildly increase the intrapelvic pressure using compression on the vulva and the lower abdomen to reduce the reflux in the pelvic veins as well as the circumference of the varicose veins. This should improve venous return from the pelvis and reduce venous stasis, both of which should alleviate PCS symptoms.

What are the potential advantages of compression therapy compared with surgical coil embolization?

Prof. Whiteley: The key advantages are cost savings and the lack of any complications. It is clearly much more advantageous to alleviate symptoms by wearing compression than to undergo an invasive procedure with expensive platinum coils. Indeed, the price for the intervention is above what many people can personally afford. Costs may also be too high in the future for health systems or insurance providers to cover. Therefore, a cost-effective treatment of the symptoms, albeit temporary rather than permanent, is an attractive option.

1 Dos Santos, S. J., Holdstock, J. M., Harrison, C. C., & Whiteley, M. S. (2016). Long-term results of transjugular coil embolisation for pelvic vein reflux – Results of the abolition of venous reflux at 6–8 years. Phlebology, 31 (7), 456–462.
Whiteley, M. S., Lewis-Shiell, C., Bishop, S. I., Davis, E. L., Fernandez-Hart, T. J., Diwakar, P., & Beckett, D. (2018). Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone – Results from two years‘ experience. Phlebology, 33 (8), 575–579.

Images: Dr. David Beckett/The Whiteley Clinic, iStockphoto.com/ttsz, Dr. med. Prakash Jayabalan