Who Makes the Diagnosis and Implement
Treatment for Pelvic Congestion Syndrome
Muhammad Assem Kubtan* and Muhammad Turki Al Abd
Department of Surgery, Syrian Private University, Syria
Submission: February 18, 2019;Published: March 11, 2019
*Corresponding author: Muhammad Assem Kubtan, Department of Surgery, Syrian Private University, Syria
How to cite this article: Muhammad A K, Muhammad T A A. Who Makes the Diagnosis and Implement Treatment for Pelvic Congestion Syndrome. Open Access J Surg. 2019; 10(3): 555787. DOI: 10.19080/OAJS.2019.10.555787.
It is well known that chronic pelvic pain (CPP) in women, commonly affects young and childbearing women in various clinical status. Approximately one third of all women commonly suffer with lower abdominal pain and they represent at least 20% of those attending outpatient gynecology appointments . Frankly this complaint usually is solvable when the real diagnosis has been made, to reach this destination it is appropriate to have a collaboration between more than one specialty, and also to have all diagnostic facilities for making up the diagnosis and implementing the proper treatment.
Objectives: Our aim in this study was to find out the incidence of the diagnosis of Pelvic Congestion Syndrome in the Syrian Society, and the implemented treatment.
Material and Methods: We conducted a retrospective study looking for women admitted to a central major hospital (Al Zehrawie Obstetric and Gynecological Diseases Hospital ZOGDH) in Damascus, Syria. Between 2017-2018 there was a 1371 admission to hospital 100%, from those being admitted, only 164 patients admitted 14% with a complaint of abdominal pain whom they were presumably subjected to clinical study and management, and the rest were normal delivery and other irrelevant diagnosis.
Results: To our surprise there was not a single case being diagnosed as PCS. Even though there were many cases subjected to Hysterectomy with no confirmed diagnosis clinically or histologically, and we failed to lay our hand on any investigation related to the diagnosis of PCS.
Conclusion: We consider that failure in making the diagnosis of PCS, does not abandon the disease presence in the community. All necessary tools required for making the diagnosis should be made available, a real collaboration should be implemented between various specialties, namely Gynecology, Vascular Surgery, and Interventional Radiology.
We live globally in a little village and no one can claim the entire knowledge in everything.
Women all over the glob share a similar complaint i.e. chronic pelvic pain (CPP) , in low income and in under developed countries women still suffer more than those belonging to Northern Countries due to, lack of advanced diagnostic facilities , due to ill collaboration between related specialties and due to invisibility of related experience in medical health profession. (CPP) has been defined as non-menstrual lower abdominal pain lasting for more than six months duration [1,2]. Those are affected represent almost 15% of women whom usually suffer from CPP due to various reasons with various predisposing factors, commonly affected women range between the ages 18-50 years old. Women suffering with CPP usually attend Gynecological Clinics seeking for a relief of this agonizing complaint and
this represent almost 10-40% of all attending outpatients’ gynecological clinics in USA. In USA it is reported that 35% of Laparoscopic interventions and 15% of Hysterectomies have been implemented due to CPP [2-5].
In this research, our target was to find out the possible incidence of women admitted with lower abdominal pain or CPP within a one year duration, and the incidence of diagnosing Pelvic Congestion Syndrome CPS.
To achieve the answer, we planned to make a retrospective research on women admitted to a major Obstetric Gynecological Hospital (ZOGDH) serving a large heavily populated area in Damascus, Syria. This is a hospital receiving mainly full term
pregnant women for normal or cesarean surgery delivery,
and partially receive patients with gynecological complaint,
and CPP. During the six months ended in 2018, there has been
1371 admission, and only 164 women 14% with an abdominal
pain complaint. Those presumably were subjected to the
investigations to find the predisposing factor to this complaint.
(Table 1) From this review we can be sure that related symptoms
during history taken was not properly asked for. Accordingly, any
following management can’t be regarded as the procedures of
i. Venous embolization i.e. inserting a venous catheter
rail road on a guide wire through the common femoral vein
in a retro grad manner into the inferior vena cava reaching
anatomically the site of left renal vein and down through
the left ovarian vein then injecting an emblazing beads to
produce a venous thrombosis, the second way is inject one
of the sclerosing agents also to create local thrombosis on
the same principle of varicose veins sclerotherapy.
ii. Laparoscopic interference, finding the dilated left
ovarian vein and blocking it by tantalum clips.
iii. The classical way of exploring the left side of retro
peritoneal space in conventional surgery and ligate the left
In the advanced communities i.e. in those of western
societies, since there is an excellent collaboration between
various specialties on equal footing, all facilities of investigation
and clinical experience are implemented within reach to make
up the diagnosis and implement the proper management to
combat this dilemma, needless to mention that adequate fruitful
and ethical collaboration between various branches of medical
specialties usually implemented. It is acceptable that women
suffering with CPP usually attend Gynecological Clinics seeking
for a relief of this agonizing complaint and this represent almost
10-40% of all attending outpatients’ gynecological clinics in USA.
In USA it is reported that 35% of Laparoscopic interventions and
15% of Hysterectomies have been implemented due to CPP [9-
Despite the number of the women admitted with this
complaint we failed to find a single case being admitted were
the diagnosis was PCS. Since the specialist in Gynecology
are variably are short of comprehending the knowledge
of investigating vascular related complaint in women and
despite the fact that almost all of them are well trained in
using ultrasound system related to obstetrics and gynecology
specialty, there is a doubt that they have the same standard of
experience in using Echo Color Doppler for vascular means, also
it is doubted that such hospitals are equipped with CT malty
slice for vascular investigation [13,14]. This problem embarks its
effects on the management of CPP in female patients attending
the gynecological clinics or even in obstetric & gynecological
specialized hospitals in the underdeveloped countries , since
the workload on hospital personnel is tremendous, and health
professionals are always pressurized to make a provisional
diagnosis and dealing with symptoms rather than diseases,
with the era of developing advanced investigations in the
vascular diseases and the establishment of a vascular specialty it
became mandatory that always there is an areas of collaboration
between various specialties, eventually for the benefit of the
patient (Figure 1).
list as a an important cause for all those women whom they
attend their clinics complaining of lower abdominal pain and
CPP, complaints of PCS in women variously present with vague
symptoms, heavy menstrual bleeding, agonizing coitus and post
coitus sever pain, and in some cases an association with vulvar
varices, or lower limbs varicosities, those finding should alert
the gynecologist dealing with such patient to the possibility of
presence of PCS.
When it come to this status unless the gynecologists are
aware of the diagnosis of PCS and how making the diagnosis, it
is mandatory to seek support from other specialist i.e. vascular
consultation. Now we can stress that there is various tools
within hand available to the vascular specialist, starting with
clinical vascular experiences, non-invasive investigations such
as Colored Echo Doppler which provide a valuable information
concerning the Venous flow within the pelvis, the competency
of the pelvic venous valves, enlarged diameter of the ovarian
and pelvic veins as well as the presence of a retrograde flow in
the ovarian veins due to venous valves incompetence, obviously
we have to mention anatomically the differences between
the right and left ovarian venous drainage proximally were
the right ovarian vein drains to the inferior vena cava directly
without any effect of hormonal or mechanical pressure from
without, while the left ovarian vein drain its blood to the left
renal vein in a right angle manner, also its connection with the
left renal vein is facing directly the orifice of the suprarenal
vein draining the supra renal gland which is loaded with vaso
constricting physiological hormones produced by the adrenal
medulla, secondly and anatomically speaking the left renal vein
commonly passing transversely anterior to abdominal aorta as it
makes its way to drain in to the inferior vena cava and posterior
to superior mesenteric artery, and sometime it is pressurized by
the abdominal aorta being pushed anteriorly, and sometime it is
pressurized by the superior mesenteric artery and posteriorly
by the anterior wall of the abdominal aorta (Nut Cracker
Syndrome ) all those mentioned effects may pave the way to the
establishment of PCS [15-21].
Whatever the case is the management of such diagnosis is
usually simple to the experienced vascular surgeon, which is
characterized by more than one technical approach. Frankly it
is unfair that women should suffer chronically from PCS , due to
delaying in making the diagnosis, for various reasons whether
due to the lack of experience or due to short of equipment’s.
It should be kept in mind that diagnosis pf PCS depends
on knowledge primarily, clinical experience, availability of
diagnostic system Colored Echo Doppler, Venography or CT
Venous multi slices. We must admit that many clinical problems
can’t be dealt with by one specialty and requires multi discipline
to be involve so reaching the best for the patient. Presumably
this is our case in underdeveloped countries where there is a
lack of collaboration for the benefit of the patients [21-27].
We consider that failure to confirm the diagnosis of PCS,
does not abandon the PCS diagnosis, but probably due to the
shortage of related facilities necessary to making this important
and bothering syndrome, secondly probably due to lack of
collaboration with experienced Radiologist able to perform
necessary investigation such as colored Echo Doppler, Pelvic
Venography, or Malty Slice Computed Venography. Vascular
Surgeons usually well orientated with conventional and
interventional venous procedures for dealing with PCS.