Pelvic Congestion Syndrome, Images, Size Criteria, Diagnosis, Imaging, Ultrasound & Testing Protocol

Pelvic Congestion Syndrome:

• What is Pelvic Congestion Syndrome?
• Images
• Size Criteria
• Diagnosis
• Imaging
• Ultrasound & Testing Protocol

What is Pelvic Congestion Syndrome?

Pelvic Congestion Syndrome (PCS) is a chronic medical condition caused by dilated and incompetent pelvic veins, leading to persistent pelvic pain, most commonly in women of reproductive age. It is often compared to varicose veins of the legs, but instead affects the ovarian and pelvic venous systems. Poor venous valve function causes blood to pool in the pelvic veins, resulting in venous enlargement, increased pressure, and ongoing discomfort.

PCS typically presents as dull, aching pelvic pain lasting longer than six months and often worsens with prolonged standing, during or after intercourse, and in the premenstrual period. Pregnancy is a major risk factor due to hormonal changes and increased venous load. Because symptoms can mimic gynecologic, urologic, or gastrointestinal conditions, pelvic congestion syndrome is frequently underdiagnosed or misdiagnosed without proper imaging and clinical suspicion.

Images

On imaging images, pelvic veins may appear enlarged and serpiginous around the uterus and ovaries. Doppler ultrasound images can show venous reflux and reduced flow velocity, especially during Valsalva maneuver. Cross-sectional imaging such as CT or MRI provides clearer visualization of pelvic venous anatomy, helping clinicians correlate symptoms with structural abnormalities seen in PCS.

Size Criteria

Size criteria are an important component in diagnosing pelvic congestion syndrome. Generally, an ovarian vein diameter of 6 mm or greater is considered abnormal and suggestive of venous insufficiency. Some studies use thresholds of 7–8 mm to improve diagnostic specificity, particularly when symptoms align with imaging findings.

Additionally, the presence of multiple dilated pelvic veins measuring more than 5 mm in diameter supports the diagnosis. Size alone is not sufficient; venous reflux, flow direction, and symptom correlation must also be considered. Using standardized size criteria helps radiologists and clinicians reduce diagnostic variability and improve confidence in identifying PCS.

Diagnosis

The diagnosis of pelvic congestion syndrome is based on a combination of clinical symptoms, physical examination, and imaging findings. Patients often report chronic pelvic pain that worsens with standing, fatigue, or after sexual activity. A detailed medical history, including pregnancies and hormonal factors, is essential to raise suspicion for PCS.

Definitive diagnosis is often achieved through imaging studies that demonstrate venous dilation and reflux. In some cases, catheter-based venography is considered the gold standard, as it allows direct visualization of venous flow patterns. Accurate diagnosis is important because targeted treatments, such as embolization, can significantly relieve symptoms.

Imaging

Imaging is the cornerstone of pelvic congestion syndrome evaluation. Ultrasound, CT, MRI, and venography each offer unique advantages. Ultrasound is often the first-line imaging modality due to its availability and lack of radiation, while CT and MRI provide more detailed anatomical assessment.

MRI is particularly useful for excluding other causes of chronic pelvic pain, such as endometriosis or fibroids, while also identifying dilated pelvic veins. Venography remains the most definitive imaging method and is often performed before interventional treatment. Selecting the appropriate imaging modality depends on clinical presentation and diagnostic goals.

Ultrasound & Testing Protocol

Ultrasound with Doppler evaluation is commonly used as an initial testing protocol for pelvic congestion syndrome. The examination is usually performed in both supine and upright positions to assess venous dilation and reflux. The Valsalva maneuver is often included to provoke venous insufficiency and improve diagnostic accuracy.

A standard testing protocol includes measuring ovarian vein diameters, assessing flow direction, and documenting venous reflux lasting more than one second. Transabdominal and transvaginal approaches may be combined for optimal visualization. When ultrasound findings are inconclusive, advanced imaging or venography is recommended to confirm the diagnosis and guide treatment planning.