Scott Webb (Host): Pelvic venous disease is more common than you might think, and my guest today wants us to know that it may be the cause of many hard-to-diagnose medical issues for both men and women. And I'm joined today by Dr. Naiem Nassiri. He's a vascular surgeon with the Vascular Care Group, and he has many years of experience diagnosing and treating pelvic venous disease.

Welcome to Answers in Vascular with the Vascular Care Group. I'm Scott Webb. Doctor, thanks for your time today. We're going to talk about pelvic venous disease. And I got a whole bunch of questions for you. So, let's just start there. What's the definition of pelvic venous disorder, and is there a clinical definition that one looks for?

Dr. Naiem Nassiri: You're correct in that there is an actual clinical definition of pelvic venous disorders previously referred to as pelvic congestion syndrome, and that terminology has been discouraged to be used, and we're leaning more towards a more global and all-encompassing terminology called pelvic venous disorders. And this tends to afflict predominantly women, but I do think it's important to mention that men can also be affected. But traditionally, this has been something that has afflicted about 25% of women of childbearing age. But that being said, even postmenopausal women can have pelvic venous disorders and complications there too.

 And as a result, I think it's important to understand the clinical implications. Typically speaking, there is a chronic, dull, achy sensation throughout the compartments of the abdomen and lower belly that tends to get worse with menstruation or periods. Then, on top of this chronic, dull, achy pain, there can be other suggestive signs and symptoms including what we call menorrhagia and/or dysmenorrhea, which means particularly heavy periods or uncomfortable periods, painful periods, profound bleeding associated with period. Also, the dyspareunia, which refers to pain with sexual intercourse, as well as flank pain or discomfort, especially on the left side. Any blood in the urine is particularly concerning, presence of bleeding, internal hemorrhoids, blood with defecation, the urge to go to the bathroom frequently to urinate, suggesting that the bladder does not have an opportunity to expand appropriately. And then, the whole slew of kind of irritable bowel syndrome folks with just painful defecations or pain that's there, or having an urge to go to the bathroom and have a bowel movement, but then having some relief after it happens.

All of these collectively fall under the umbrella of the all-encompassing term, pelvic venous disorders. And I think it is very important for all specialists to have an awareness of a potential for a very common entity attributable to venous or vascular disorders causing these types of very common symptomatology.

A lot of women are suffering silently, and they think that's part of the process of being a woman. We just have aches and pains and they tend to suffer and take this on. And the good news is that this really need not happen. There are very much highly organic and identifiable sources for this pain and discomfort that is pertaining to the vasculature. So, those are some of the things that are classically associated with this pelvic venous disorder.

Host : Yeah. Wondering why so many women, I know you said this also affects men. But primarily women, why so many women are underdiagnosed and undertreated for pelvic venous disorders?

Dr. Naiem Nassiri: Some of those I touched upon, I think women by virtue of the hormonal fluctuations that take place on a monthly basis, they attribute a lot of it to menstruation, and they tend to just say it is what it is, and they have a very high pain tolerance and they suffer silently, and people attribute it or chalk it off to hormones or stress and things like that. And they think "Well, this is part of the process of being a woman and they take this on unnecessarily, especially women who've had at least two pregnancies. The two pregnancies in my 15-year experience tends to be that magical number. I think that really leads to the onset of manifestation of some of these signs and symptoms. But women who haven't been pregnant before can also be affected, like teenagers who have just started getting their periods can be affected, but pregnancy tends to really wreak havoc on women's vasculature and really brings this on.

The other explanation for this is, really limited amount of awareness in the gynecology community pertaining to a correlation with pains and discomforts pertaining to the pelvic and abdomen that are vascular in etiology and just that lack of awareness and communication that exists between colleagues in Gynecology and folks in Vascular Surgery.

Furthermore, even in the field of Vascular Surgery, there are very few specialists vascular surgeons who have the clinical insight and clinical awareness to know when and how and via what routes to look for these etiologies. And even if they can diagnose it, then there are no specific set in stone algorithms that folks have employed to be able to treat these lesions. In other words, even if it's identified, not everybody really knows how to treat these. And so, the collective nature of all these things I talked about together really leads to a highly elusive, underappreciated, underdiagnosed, and frankly, undertreated entity amongst women of childbearing age.

Host : Yeah. And you mentioned the sort of classic signs and symptoms associated with pelvic venous disorders. Wondering, since it's possible for men to be afflicted as well, what would be some of the signs and symptoms for men, I guess?

Dr. Naiem Nassiri: I think men tend to present a bit more because men don't have these monthly fluctuations. Men do not have to bear the pain and discomfort that many women deal with on a monthly basis. They tend to have a lower threshold for some of these pains and discomfort. So, we tend to see it more commonly in men. But actually, pelvic venous disorders are one of the most common causes of male infertility. And that has to do with the relation of the testicles and the venous structures that are abutting and associated with that. For example, the spermatic veins in correlation with the structures within the testicles that produce sperm. And temperature fluctuations within the testicular milieu that can be affected by the amount of pressure from a vascular standpoint that exists on the testes. Those can have an impact on the motility and capability of the sperm to fertilize an egg. And so, I would say that that's actually one of the most under recognized causes of male infertility amongst men. And I would say it is probably the most underinvestigated causes of male infertility globally.

Host : Yeah. It's really fascinating. You gave us a little bit of a sense there of maybe why, especially in women, it's underdiagnosed and undertreated. Just wondering, how does one go about identifying the appropriate specialist for diagnosis and treatment of these disorders?

Dr. Naiem Nassiri: So, women tend to, in addition to their primary care doctor, most women, I would say not all, of course, have a gynecologist or an obstetrician whom they have worked with or see closely. And I would say that I do think it's imperative for some of the very common entities that can be involved, for example, uterine fibroids, endometriosis, ovarian cysts, ovarian torsion, neoplasms, and cancers and all that stuff urinary tract infections, et cetera, et cetera. It is important for all those things to be ruled out. And those can be ruled out fairly quickly. I have no qualms and issues with colleagues in Gynecology really investigating those for us. But I think once those things have been ruled out or ruled in and treated, and then there's persistent pain and discomfort, that's when a very highly specialized vascular surgeon really well versed in the diagnosis treatment and the algorithms involved in the minimally invasive treatment of these things needs to get involved.

And I do think it's important to recognize that even in Vascular Surgery, not all vascular surgeons really have the interest or the expertise, frankly, and the knowledge and the skill set to be able to tackle these things. It does require someone who's really dedicated their career to this particular phenomenon.

And I do think that probably the most important thing is a very good dialogue between a highly specialized vascular surgeon and the referring Gynecology team or Urology or primary care doctor and then not necessarily chalking these things up to anxiety issues and all kinds of psychiatric disorders or these vague syndromes and pain diagnoses that have been given, such as complex regional pain syndrome or fibromyalgia or anxiety disorder. And I can't tell you how many young, middle-aged and older women have been given all sorts of psychological and psychiatric diagnoses based on something that was frankly a very organic and easily explicable vascular pathology. I've had married couples whose marriages was falling apart really unhappy in the marriage due to a limited ability to have sexual intercourse and physical intimacy. And we were able to really save the marriage and be able to provide relief for these patients and say there's a whole slew of tests that can be ordered diagnostically.

The problem with a lot of these tests, including CAT scans and MRIs is that the position of the patient, which is supine or flat, can mask pathology that can be there that really needs the patient to be in an upright position or with the legs down or head up position. And so, based on these missed diagnoses, I actually have started to forego some of the traditionally recommended imaging modalities such as CT scans and MRIs. And I go directly to a very small diagnostic procedure done in the comfort of my own office where I basically put an intravenous or a small IV similar to what you would get when you go and get blood drawn. And through that, I perform what's called a venogram, which is a dye shot within the veins under x-ray guidance. And I also perform IVUS or intravascular ultrasound. IVUS is I-V-U-S and that is a probe maybe a little bit smaller than a Q tip that is slid inside the veins. And it gives me very highly precise measurements of the culprit areas that I know to look for, such as the gonadal vein, the renal vein, the inferior vena cava, and the iliac veins. And based on these measurements, along with the venogram that I perform, I can delineate exactly what the causes and pathways of pathology are that is causing this global phenomenon of pelvic venous disorders, which in essence is basically vascular venous congestion caused by venous hypertension due to a variety of different compression processes, pinching of the veins, reflux of the veins, which means pulling of the blood against gravity towards the feet area that can cause basically varicose veins in the vaginal area, in the vulvar region, near the uterus, near the ovaries, near the kidneys, throughout the abdomen, et cetera.

Host : Yeah. This is so fascinating. I am learning so much from you today, as I'm sure listeners are as well. Wondering what's the proper therapeutic pathway for treating these elusive pathologies that afflict women.

Dr. Naiem Nassiri: When one knows where to look for, these are basically a very intricate and interconnected networks of venous flow patterns that are all tied in together, right? And one needs to correlate the patient's symptomatology with the pathology that's identified. And an algorithm needs to be placed such that the therapy matches the symptomatology and the patient's complaints. And so, depending on what the anatomy of the pathology is, and depending on what the patient's symptoms are, then treatment needs to follow an algorithm that matches that. For example, if there are areas where the veins are pinched, the veins can be opened with balloons and/or stents based on intravascular ultrasound guidance.

If there are areas where, for example, there is incompetence or pooling of the blood through a vein due to gravity, but against the typical flow patterns that one would expect, and blood is therefore pooling downwards towards the feet, then some of those veins can then be embolized or plugged so that vein that is not functioning is not carrying blood and so the blood gets redirected to veins that are functioning. You can think of it as a traffic jam on an interstate highway where the five-lane highway due to construction or an accident has become a one-lane highway. And so, there's congestion there and there's traffic, if you will, backed up through all the little side streets. And so, one basically needs to alleviate that traffic jam and open the highway back up. That's really the first step. Then, one needs to clear up all the side alleys and side streets that have been congested with excessive traffic and redirect the traffic back into that interstate highway that is a nice, large, open, five-lane highway. That is a very good analogy that I like to use that really helps people understand exactly what it is that we're trying to accomplish here.

But I think the most important thing is that you can't just do the same thing for everybody. You have to correlate the patient's symptoms with the anatomy that you decipher based on your diagnostic maneuvers and then be able to surveillance and then follow up that patient regularly going forward and kind of know where to look for what and how to treat what.

Host : Yeah. I appreciate that analogy. Certainly, we've all been there of course, and it helps work for lay people like myself, the ones hosting these things with experts like yourself. Just give you a chance here at the end, Doctor, final thoughts and takeaways about pelvic venous disease.

Dr. Naiem Nassiri: Highly, Highly underdiagnosed based on my experience. I believe that almost everybody in that sort of suggestive age group and sex tends to be affected by these. It's just a matter of have they gotten the environmental hits such as multiple pregnancies or having a first degree relative that has the disease process or other sorts of external trauma, so on and so forth. Do they have the environmental hits and the genetic predisposition to lead to profound symptoms? If they're completely asymptomatic, even sometimes and they have risk factors for certain other pathologies, for example, if someone has a profound compression of the iliac vein, is otherwise asymptomatic, but tends to have on top of that either benign or malignant tumor diagnosis or has a genetic predisposition to forming clots or has had previous blood clots, those patients ought to be treated because while it is a silent process at that time, there can be complications associated with it afterwards.

The other thing I would say is that folks who may have blood in their urine that have seen colleagues in Urology and Gynecology, have had the whole gamut of testing done and they can't figure out why this patient is having bleeding, I would say that a vast majority of them should be investigated for pelvic venous disorders and to see a highly specialized vascular surgeon. So, the most important takeaway message is that this disease process is highly common, but unfortunately the expertise and the awareness tends to be limited. So, I'm hoping that this podcast gets the word out to a lot of patients. So if they have the pain and discomfort that no one can really help understand and explain why, there's no need to suffer in silence. You may very well have an organic problem that has not been investigated and people are just telling you that you're anxious or you have this regional pain syndrome, go see a pain specialist, so on and so forth so you don't need to suffer silently. Come and see someone who knows what they're talking about and let's figure out what we can do to help you.

Host : Yeah. That's perfect. As you say, it's common, it's underdiagnosed, it's undertreated. And if all else fails or after all else has failed, really go see a vascular surgeon who specializes in pelvic venous disorders. This has been really good stuff today. I really appreciate your time. Thanks so much.

Dr. Naiem Nassiri: No problem. Thank you.

Host : And for more information, please visit our website at thevascularcaregroup.com. Thank you so much for listening to Answers in Vascular with the Vascular Care Group. I'm Scott Webb. Thanks for joining us.