Chronic pelvic venous insufficiency: from complaint to targeted management

• Simple organizational chart:
  Step 1: clinical (pelvic pain, perineal/MI varicose veins, dyspareunia).
• Step 2: Doppler ultrasound.
• Step 3: MRI / CT scan if IVPC is suspected.
• Step 4: Phlebography + endovascular procedure if symptoms are severe or resistant.

Conservative treatment remains a first-line option for patients with few symptoms, in the recent postpartum period, or while awaiting interventional management.[4][8][3]

• Venous compression (shorts or tights for pelvic and lower limb compression).[8][4]
• Drug treatments: NSAIDs, progestins (e.g., medroxyprogesterone acetate), GnRH analogues, or contraceptive implants in certain situations, to reduce congestion and pain.[4][8]
• Hygienic and dietary measures: weight control, regular physical activity, adaptation of prolonged positions, management of triggering hormonal factors.

These measures may be sufficient for some patients, but high-quality evidence remains limited, and severe symptoms warrant interventional treatments.[8][3]

e

For highly symptomatic patients, embolization of pathological pelvic veins and, if necessary, correction of iliac or renal venous obstruction now constitute the core of treatment.[7][9][2][5][3]

Endovascular embolization has become the standard treatment for symptomatic pelvic venous reflux, supported by recent recommendations from learned societies (AVF, ESVS).[2][5][3]

• Venous access (often jugular or femoral), selective catheterization of the ovarian and internal iliac veins under fluoroscopy.[9][10][7]
• Embolization with coils (sometimes associated with sclerosing agents or plugs) until complete occlusion is achieved and reflux disappears.[10][7][9][3]
• It is possible to supplement this treatment with sclerotherapy of the vulvar and perineal networks or with phlebectomies of superficial escape varicose veins.[7][3]

Clinical series report an improvement in pelvic symptoms in 80–90% of cases in the medium term, with low morbidity.[5][2][3][7]

When PCIV is associated with significant iliac venous obstruction (May-Thurner syndrome) or renocaval compression, simple embolization may not be sufficient.[2][3][5]

• Placement of an iliac vein stent in cases of hemodynamically significant stenosis and severe symptoms.[10][3][5][2]
• Depending on the series, a sequential strategy is often preferred: correction of the obstruction (stent) then complementary embolization if symptoms or reflux persist.[5][2]

Studies show that normalizing abdominal, pelvic and lower limb venous flow significantly improves the quality of life of these patients.[3][5]