Background/Purpose: Background: The pelvic congestion syndrome (PCS) is an under and often misdiagnosed entity that appears more frequently in premenopausal age and multiparous women. The pathophysiology consists of a sum of phenomena including venous stasis and inversion of the pelvic venous flow that cause varicose veins and congestion. The left ovarian vein is usually the most affected. Typically it presents as a dull, chronic abdominal-pelvic (AP) pain, which worsens with menstruation and prolonged standing, and lasts longer than six months. Pain is associated with dyspareunia and varicosities in lower limbs (LL) and genitals. It is challenging and important to consider atypical clinical presentations that simulate osteoarticular (OA) pathologies. It is usually diagnosed by Angio-CT, and a safe, definitive and successful treatment is the embolization of the affected vein.
Purpose: to evaluate the characteristics of those patients diagnosed with PCS in our University hospital from January 2014 to May 2018, paying close attention to the atypical forms of presentation that simulate OA pathology.

Methods: We included all patients from our center who were operated by embolization due to a PCS from January 2014 to May 2018. Socio-demographic variables, forms of presentation, pain characteristics, associated symptoms, patient management and outcome data were collected.

Results: Sixty women were included with a mean age of 43 years at diagnosis, 87% (n=52) were multiparous, with a mean of 2 previous pregnancies. In 95% (57) of all cases the duration of symptoms until the diagnosis exceeded 6 months. Patients were classified according to presence and location of pain in 4 groups: 1. Women with AP pain, 23% (14); 2. Women with OA pain 5% (3); 3. Women with mixed AP and OA pain, 59% (35); and 4. Women with other symptoms 13% (8). Regarding patients from groups 2 and 3 (only OA pain or mixed pain) (38), 90% (34) of them presented low back pain, 53% (20) hip pain and 40% (15) sciatic pain. Only 5% (3) of all patients were evaluated by a rheumatologist.

As for the pain characteristics from groups 1, 2 and 3 (52), in 72% (37) of patients it was diurnal, in 48% (25) it worsened with menstruation, in 62% (32) it worsened with prolonged standing and in 35% (18) it worsened at rest. Among the associated manifestations, stand out the presence of LL varicose veins in 74% (38) of patients, genital varicosities in 58% (30), dyspareunia in 42% (22), dysmenorrhea in 40% (21), hemorrhoids in 37% (19) and dysuria in 18% (9). All patients underwent embolization of the affected vein, with an initial Visual Analogue Scale (VAS) mean of 7.38 over 10, and final VAS mean of 2.63. The mean recovery time was 36 days. The evolution was good or very good in 84% (32) of patients with mixed (AP and OA) pain and in 57% (8) of those who only had AP pain. Less than 2% (1) had a recurrence without the need for reoperation.

Conclusion: PCS is a rare entity, typically associated with long lasting AP pain, but, in more than half the cases, is accompanied with OA symptoms, mainly low back pain. It is important and challenging for the rheumatologist to identify these patients, since treatment is usually safe and effective, and diagnostic delay worsens their quality of life.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pelvic-congestion-syndrome-an-uncommon-cause-of-osteoarticular-pain/