Joey Wahler (Host): It can cause significant pain. So, we're discussing pelvic venous congestion. Our guest is Dr. Arun Jagannathan. He's an interventional radiologist. This is iMatter Health, a Silver Cross Hospital podcast. Thanks so much for joining us. I am Joey Wahler. Hi there, Doctor. Welcome.

Arun Jagannathan, MD: Thanks for having on, Joey. I appreciate it.

Host: Absolutely. Same here. So first, in a nutshell, for those not entirely familiar, what exactly is pelvic venous congestion? And what's the most significant way that it differs from, say, other causes of pelvic pain?

Arun Jagannathan, MD: I think an excellent analogy to pelvic venous congestion is varicose veins in the legs. Essentially, it's the same process that occurs within the legs in which the blood flow that should be directed from the legs to the heart actually refluxes down and forms large varicose veins resulting in edema, heaviness, aching, and other issues within the lower extremities.

The analogous situation in the pelvis is that we have veins that typically will drain the uterus and ovaries that are no longer functioning appropriately, and then allow the blood to then back up into those vessels, congest the organs, and result in a chronic inflammatory process.

Host: Gotcha. And so, what typically causes this? Why does it happen?

Arun Jagannathan, MD: So, it's something that's actually very common and it tends to occur over time. As women age, as women have more children, increases the chances of this process occurring. Essentially, the valves within the veins, when they are functioning appropriately, they will open basically towards the heart, allowing the blood only to move in one direction.

As the veins increase in size over time and with additional pregnancies and age, the valves no longer are able to touch. And what happens is the blood then starts refluxing down, filling those organs, and then causing this congestive picture.

Host: And so, you mentioned women. This is not something that affects men then?

Arun Jagannathan, MD: There is an analogous condition in men called varicocele where these same vessels will then form varicose veins within the scrotum. So yes, there is an analog, but this specific disease process is only amongst women.

Host: Okay. So, what symptoms typically should raise suspicion that this may be taking place?

Arun Jagannathan, MD: So, the symptoms that we typically like to see that are most concordant with this process are symptoms that progress over the course of the day, that progress with patients spending more time on their feet, and that is increasing heaviness, aching, swelling, and pain within the pelvis. We can oftentimes also have patients that experience pain that worsens around menstruation, that worsens around intercourse. And that can sometimes develop visible varicosities in the medial kind of upper thigh area, groin area, and in the vulvar region. So, those are all things that are oftentimes seen with this disease process.

Host: I understand, Doctor, that pelvic venous congestion often can go undiagnosed for years. So with those kind of seemingly overt symptoms, why is that?

Arun Jagannathan, MD: The difficulty is sometimes teasing these symptoms out and differentiating them from other causes of chronic pelvic pain, which there could be several. And there are several causes within the gynecological area itself, including ovarian cysts, fibroids, endometriosis, all of those things can cause chronic pelvic pain as well as urologic causes, bladder-related issues, and GI issues as well. So, being able to differentiate this process from these other processes can be sometimes difficult without having someone who can review the imaging and tease out these particular symptoms and the specificity of these symptoms.

Host: Understood. And so, speaking of someone that can view it and differentiate like yourself. In layman's terms, how do you go about diagnosing this when all of those different things might be in play?

Arun Jagannathan, MD: Many of these patients have already had prior imaging, oftentimes many different types of imaging, including ultrasound of the pelvis, including CT scans, and sometimes MRIs. We can demonstrate on some of these imaging exams that there is ovarian vein reflux, which can sometimes be concordant with the patient's symptoms. Now, we take the patient's symptoms and the clinical picture, and we marry that with the imaging findings. And between those two things, we can demonstrate that there is a high likelihood that the patient's symptoms may be related to ovarian vein reflux and/or other type of venous compression symptoms.

Host: So having said that, just to be clear, if someone is told they have pelvic varicosities or ovarian vein reflux based on their CT, which you mentioned, or other imaging scan, does that necessarily mean they have pelvic congestion syndrome and need treatment or no?

Arun Jagannathan, MD: No, it does not. So, there has to be symptoms that match that picture. And the most specific symptom is progressive pain over the course of the day with a patient in an upright or standing position that is then alleviated when the patient lays down. So, these patients oftentimes will find that they need to lay down and rest over the course of the day in order to be able to make it through the day, because their pain has become so severe and significant. So, patients that come in with that particular history and have imaging findings of ovarian vein reflux, those two factors together are highly specific for this disease process.

Host: Is there anything women can do to guard against this to try to prevent it, or is it going to happen one way or another if it's going to happen?

Arun Jagannathan, MD: Unfortunately, there's nothing that you can do. The genetic predisposition to developing vein disease oftentimes is something that runs in families and patients will oftentimes come and say that they have these symptoms. They have a mother or grandmother potentially that had had varicose veins before, as well as possibly even pelvic congestion that had just gone undiagnosed. Because up until probably about 10 to 15 years ago, the awareness of this disease process was very low. So, a lot of times these women, they have had a family history of pelvic venous varicose disease. It just never was diagnosed or treated in the past.

Host: Now, you've mentioned varicose veins a few times. If you have that, does it mean you might be more likely to get the other?

Arun Jagannathan, MD: It does, it does.

Host: So, what treatment options are available, be it surgical or otherwise?

Arun Jagannathan, MD: So, treatment options are essentially the only treatment option at this time that is considered the standard of care is endovascular minimally invasive treatment. These are essentially not treated surgically anymore because of the morbidity and mortality related with it, the long recovery times from a surgical intervention to treat this, as well as very low efficacy, meaning it just doesn't work very well.

So, the mainstay of treatment, the gold standard of treatment is embolization, meaning closure of the abnormal leaking veins. And that's something that we do as interventional radiologists.

Host: So, what would that procedure be like? What can people expect?

Arun Jagannathan, MD: It's an outpatient procedure that typically takes anywhere from an hour to an hour and a half. It's done under conscious sedation, so patients are not under general anesthesia. They go home with a small incision. Sometimes we'll do an incision in the neck, and sometimes it'll be an incision in the groin. But these are very small incisions that don't even require a suture to close. And they can go home the same-day typically, and then we'll see them in follow-up. And then, we expect over the course of a few weeks to a month or two significant improvement in the symptoms.

Host: I have to tell you, Doctor, that it seems more and more lately when I interview physicians, they're talking about life-changing procedures where people are in and out the same day, right? It seems like this is something that's new and advanced just as of recent years, and it seems like it's reaching all branches of medicine, right?

Arun Jagannathan, MD: Yes, that's absolutely correct. This is the way things are going, either minimally invasive approaches or other types of minimally invasive surgical options. But in this case, minimally invasive endovascular treatment is the gold standard.

Host: A couple of other things for you. What's life like after this treatment? How quickly do patients feel relief?

Arun Jagannathan, MD: So typically, what I tell patients is it is similar to treatment of varicose veins in their legs, in that we will sometimes inject medications to close down the abnormal varicosities as well as the source of the varicosities. And by using these medications, it can cause an inflammatory reaction, which is exactly what we want to happen. We want those veins to close down. So, they can expect over the course of seven to 10 days some mild aching and burning in that area in the pelvic region, that will then gradually improve with the final results typically declaring themselves within two to three months.

So, I tell patients, give it a couple of months, while that initial inflammation from our treatment goes away, and then we'll have a better sense of the final outcome. And typically, we see anywhere from 85-90% of patients that have a significant positive response.

Host: When they get those kind of results, does this ever have to be done again down the road, or does that hold for the foreseeable future?

Arun Jagannathan, MD: In some situations, there's a complex network of veins in the pelvis in which there are multiple other refluxing varicose veins that could also be contributing to this process. We do assess all of these veins when we do our procedure, but we don't necessarily treat every vein the initial procedure. We will follow these patients. If they have recurrence of symptoms, they may have other syndromes that may be causing problems, including nutcracker syndrome, where the left renal vein may be compressed. They may have a May-Thurner syndrome where the left common iliac vein may be compressed by adjacent structures. Those may also need to be treated. We don't do that typically all in the same setting. But in some patients, we do need to go back and do some additional treatment of other areas of compression, venous compress.

Host: Now, someone joining us, Doctor, has been told everything looks "normal," but yet they're still having pelvic pain, what would you tell them to do?

Arun Jagannathan, MD: I would tell them, if they have symptoms that are concordant, meaning if they have symptoms that are matching what we expect to see in someone who has pelvic venous congestion that, even if they have not had findings on the conventional imaging that they've had, that they request a referral for specific imaging that may demonstrate this process.

There are particular types of pelvic ultrasounds that are more specific in evaluating this. There are specific types of CT and MRI scans that are better at evaluating this process. If your primary care doctor or gynecologist is not as familiar with these things, then I would recommend that they send a referral to an interventional radiologist who can then determine what the appropriate imaging test is.

Host: In summary here, what's your main message to those joining us that have this condition? It would appear based on what you said, that if nothing else, this can be successfully treated in most cases, right?

Arun Jagannathan, MD: Yes, correct. And there's a lot of patients, and actually the majority of patients that we see have been going undiagnosed and suffering from these symptoms for a long period of time. And they've had workups by both gastroenterology, sometimes OB and urology to evaluate the other organs that could potentially cause pelvic pain. And all of those have turned up negative. And some of those patients are still suffering from significant symptoms from this disease process, which has just gone on to underdiagnosed. So, I would just tell a patient if they have symptoms concordant to this, despite all of the other testing having been negative, just to make sure that the appropriate testing for this has been done as well.

Host: Great advice indeed. As you pointed out, it does often go undiagnosed. Well, folks, we trust you are now more familiar with pelvic venous congestion. Doctor, great advice indeed. Keep up all your great work. And thanks so much again.

Arun Jagannathan, MD: Thank you, Joey. Appreciate it.

Host: Same here. And for more information, please do visit silvercross.org/pelvicpain. If you found this podcast helpful, please do share it on your social media. And thanks so much again for being part of iMatter Health, a Silver Cross Hospital podcast.