“You’ve seen multiple doctors. You’ve been told it’s a urinary infection… again. You’ve had blood tests, pap smears, ultrasounds, even endoscopies. But the pain is still there—and no one has offered a clear answer.”
This is the experience of many women suffering from Pelvic Congestion Syndrome (PCS)—a widely underdiagnosed vascular condition that can cause chronic pelvic pain for years before a proper diagnosis is made.
What Is Pelvic Congestion Syndrome?
Pelvic Congestion Syndrome is a form of chronic pelvic venous insufficiency caused by dilated and incompetent ovarian or pelvic veins. It results in blood pooling in the pelvis and lower abdomen, leading to pressure, heaviness, and chronic discomfort.
PCS is most common in women of childbearing age, especially those who have had multiple pregnancies. It is frequently overlooked or misdiagnosed, resulting in years of unnecessary testing and ineffective treatments.
The Hidden Veins Behind the Pain
Unlike varicose veins in the legs, pelvic varicose veins are not visible externally. They often affect the:
- Ovarian veins
- Internal iliac veins
- Pelvic venous plexus
Because these veins are deep and hard to image, and because their symptoms overlap with those of gynecologic, urologic, and gastrointestinal disorders, PCS is commonly missed or misinterpreted.
How Does Pelvic Congestion Present?
The hallmark symptom is chronic pelvic pain that:
- Lasts more than 6 months
- Worsens with prolonged sitting or standing
- Is relieved by lying down
- May intensify after intercourse (dyspareunia), before menstruation, or after physical activity
Other associated findings:
- Visible or painful varicose veins in the vulva, inner thighs, or buttocks
- Sensation of pelvic heaviness or pressure
- Urinary urgency or pelvic floor discomfort
These patients are often dismissed or misdiagnosed—frequently told their symptoms are related to:
- Recurrent urinary tract infections
- Endometriosis
- Irritable bowel syndrome
- Psychosomatic complaints
A Diagnostic Odyssey: The Missed Diagnosis of PCS
Women with PCS often go through years of incorrect or incomplete evaluations, including:
- Multiple gynecological consultations
- Repeated antibiotic courses for assumed urinary infections
- Endoscopies for non-specific abdominal complaints
- Laparoscopies for suspected endometriosis
- Being told that “nothing is wrong” on standard pelvic ultrasounds
Unfortunately, transabdominal or even transvaginal ultrasound may fail to detect pelvic vein reflux unless performed with specific intent and technique. Many patients are told that their imaging is “normal,” even though their pain persists.
How Is PCS Diagnosed?
A thorough diagnostic approach includes:
- Pelvic color Doppler ultrasound, ideally performed with the patient in an upright position and during a Valsalva maneuver
- CT or MR venography, to visualize dilated pelvic veins and assess reflux
- In certain cases, pelvic venography (an invasive test) remains the gold standard for both diagnosis and treatment planning
Accurate imaging requires clinical suspicion—if PCS is not considered, it is not investigated.
How Is It Treated?
The treatment of PCS is minimally invasive and performed by interventional techniques. Surgical treatment is rarely necessary.
Endovascular treatment options include:
- Catheter-directed embolization of the ovarian and/or internal iliac veins using:
- Coils
- Sclerosant foam
- Sometimes glue or plugs
This procedure is typically done on an outpatient basis, under local anesthesia, and has a high rate of symptom relief.
Why Awareness Matters
Pelvic Congestion Syndrome is a real, treatable condition. Yet because its symptoms overlap with many other disorders and because standard imaging often overlooks it, many women suffer in silence—or are told the pain is “in their head.”
Raising awareness among healthcare providers and patients is critical to:
- Avoid unnecessary antibiotics, surgeries, or invasive tests
- Reduce chronic pain and improve quality of life
- Ensure that vascular causes of pelvic pain are part of every differential diagnosis
Conclusion
Pelvic Congestion Syndrome remains one of the most underdiagnosed causes of chronic pelvic pain in women. Characterized by dilated ovarian and pelvic veins, it often evades detection through conventional gynecologic evaluations and general imaging.
If chronic pelvic pain has persisted without clear cause, and especially if it worsens with standing or is associated with pelvic or thigh varicose veins, a vascular evaluation should be considered. Recognition and appropriate treatment can offer lasting relief for patients who have often struggled for years without answers.
