Pelvic Congestion Syndrome (PCS)

Pelvic congestion syndrome (PCS) can be thought of as “varicose veins in the pelvis”. Increasing interest in the subject over the last 2 decades has increased the understanding of the condition. Contrary to early reports, it can affect men as well as women, and in women affects nulliparous women and post-menopausal women, as well as those that are fertile. Although there is a push towards renaming it pelvic venous disorders (PeVD), it is still widely called PCS and so this is the term used here. Although grading systems have been suggested, currently it is easiest to grade PCS into symptoms and signs: (1) Symptoms: A—Inside the pelvis, B—Outside the pelvis, (2) Signs (varices) A—On the pelvis/lower abdomen, B—Legs—and then O = Obstruction and/or R = reflux. Cross sectional imaging such as CT, MRI and IVUS are likely to overestimate the effect of any obstruction, and venography relying in diameter and non-physiological flows of injected contrast are similarly suspect. Use of the transvaginal duplex ultrasound using the Holdstock-Harrison protocol combined with transabdominal duplex ultrasound using sitting, lying and reverse Trendelenburg (Holdstock-White Protocol) – combined with single cuff air plethysmography iliac obstruction is suspected - gives the optimal functional investigation, and results in reflux being found as the cause in 98% of our non-post thrombotic patients. We believe that many PCS patients are having stents placed in normal veins on imaging alone and suspect this will lead to clinical and medicolegal problems in the future. Hence, our advice that a patient has to “earn their stent”.