Ovarian Vein Embolization for Pelvic Congestion Syndrome

and to obtain requisite cytologic and bacteriologic specimens, imens. The pelvic examination should always be initiated with a single index finger, finger, flrst first noting any introital tenderness or spasm. Next, the levator ani muscles are direcdy directly palpated for tone and tenderness. The insertion of the levators should also be palpated if possible, laterally at the arcus tendinei and anteriorly at the pubic rami. The urethral and trigonal areas should be gently palpated to elicit any areas of tenderness, induration, or thickening. thickening. The urethra should also be massaged to elicit any secretions. Then the "gutter" on either side of the urethra should be evaluated for any fullness, fluctuance, fiuctuance, of discomfort that might suggest a urethral diverticulum ~The bladder base is also evaluated or vaginal wall cyst. The for tenderness. With deeper palpation, evaluation for cervical or vaginal fomiceal forniceal tenderness is done. The piriformis, coccygeus, and obturator internus should also be palpated for tenderness that reproduces pelvic pain. The craditional traditional bimanual examination is the last portion ofd1e of the pelvic examination in the pelvic pain patient. A fixed, retroverted uterus may suggest endometriosis or cul-de-sac adhesions. Endometriosis is also suggested by tenderness of the posterior uterus, uterus, nodularity of the uterosacral ligaments and cul-de-sac, and narrowing of the posterior vaginal fornix. fomL"\(. However, pelvic nodularity is not diagnostic of endometriosis and may occur with other conditions, particularly ovarian carcinoma. Asymmetric, enlarged ovaries, particularly if fixed to the broad ligament or pelvic Sidewall, may imply the presence of endometriosis. Bilateral or unilateral ovarian tenderness almost always occurs with pelvic congestion syndrome. Marked discomfort with digital rectal examination often accompanies irritable bowel syndrome or chronic constipation, as may hard feces in the rectum. Function of the internal and external anal sphincter should be evaluated by reflex "wink" and voluntary constriction. Rectal examination should also include evaluation for rectal Reoal ma5ses, as many coloreetal colorectal carcinoma5 masses, carcinomas are palpable this way. Basic sensory testing to sharpness, dullness, and light touch may be indicated, as well as muscle strength testing and deep tendon reflexes of the trunk and lower extremities. Further neurologic, musculoskeletal, gastrointestinal, gynecologic, and urologic aspects of the physical examination may be needed, based on the clinical hiStory. history. Consultation outside the gynecologist's areas of expertise expeltise should be obtained. Laboratory & Diagnostic Studies Most women with chronic c11fonic pelvic pain should have cervical cultures or smears for gonorrhea and chlamydia, complete blood cell count, sedimentation rate, stool guiaic testing, urinalysis, and urine culture. Other tests depend on the history and physical findings. flndings. For example, if the urethra is red or swollen, urethral cultures are needed. Imaging studies are mostly useful to rule out speciflc specific diagnoses suggested by the clinical flndings. findings. For example, intravenous pyelography, cystography, skeletal or

pelViC pelvic x-rays, ultrasound, and cr scans may each be useful in certain patients, but certainly should not be done routinely. Defecography and vaginograms may occaSionally casionally be helpful if pelvic floor defects are thought to be contributing to CPP. Transuterine or retrograde venography is indicated if pelvic congestion syndrome is a possible diagnosis. Cystoscourethroscopy and urodynamic studies are indicated if there are any urinary tract symptoms. Pelvic nerve studies may prove to be useful in pelvic floor myalgias, but much more exploration is needed before their role is established. Diagnostic laparoscopy is often done in the evaluation of pelvic pain and in fact pelvic pain is the most common indication for diagnostic laparoscopy.

References 1. Reiter RC jc. Nongynecologic somatic RC,, Gambone Jc. pathology in women with chronic pelvic pain and 36,253. negative laparoscopy. J Reprod Med 1991; 36:253.

2. SteegeJF, Steege JF, SroutAL. Stout A1. Resolution of chronic pelvic pelViC pain after laparoscopic lysis of adhesions. Am J Obstet 165,278 Gynecol 1991; 165:278 3, Howard FM. The role of laparoscopy in the evalua3. tion of chronic pelvic pain: promise and pitfalls. 48,10-46. Obstet Gynecol Survey 1993; 48:10-46. 4. Steege JF. jF. Assessment and treatment of chronic pel4. vic pain. pain. Telinde's Operative Gynecology Updates 1992; 1:1-10. U-10. 5, Reiter RC. A profile of women with chronic pelvic 5. pain. Clin Obstet Gynecol1990; Gynecol 1990; 33:130-138. 33,130 - 138. 6. 6. Reiter RC. Chronic pelvic pain: forward. Clin Obstet Gynecol 1990; 33,117-8. 33:117-8. 7. Rapkin AJ. Neuroanatomy, neurophysiology, and neuropharmacology of pelvic pain, pain. Clin Obstet Gynecol 1990; 33,119. 33:119. EM. The diagnosis of intersititial cystitis. 8. Messing EM. J Uro!(suppl)I989; 29A - 21. Urol(suppl)1989; 29:4-21. 9. Summit RLJr. Urogynecologic causes of chronic pel9. vic pain. Obstet Gynecol Clin N Am 1993; 20:68520,68:;698. 10. Baker PK. PI<. Musculoskeletal origins of chronic pelvic 20,71 9-742. pain. Obstet Gynecol Clin N Am 1993; 20:719-742.

11. Slocumb Jc. jc. Neurologic factors in chronic pelvic pain: trigger points and the abdominal pelViC pelvic pain syndrome. Am JJ Obstet Gynecol 1984; 149:536. 149j36. 12. Applegate WV. Abdominal cutaneous cutaneOLlS nerve entrap-

ment syndrome. Surgery 1972; 71:118. n118. 1:30 pm Ovarian Vein Embolization for Pelvic Congestion Syndrome l.indsay Machan, MD Lindsay University of British Columbia Hospital Vancouver, BC, Canada

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Chronic Chronic pelvic pain is one of o f the most frustrating and common commo n problems proble ms encountered in gynecology. gynecology. Chronic ned as "pain pain defined "pa in that is present for at least 6 pain isis den months" months" (1). (1). In laparoscopic studies, approximately one third of patients third o f patients with chronic pelvic pain have endometriosis, triosis , one one third have other structural stru ctural abnormalities, and one one third third have no obvious nndings fi ndings (2). (2). Because of the nature nature and chronicity of the pain the symptom complex becomes intettwined intettwined with alterations in daily function, fu nction, and and interpersonal interpersonal relationships and there is often a sig· significanr psychologic overlay. Therefore, chronic pelvic nificant chron ic pain difficult problem for the clinician to LO manage and pain isis aa difn.cult is is often often refractory to surgical therapy. Varicosities Va ricosities in the pelvis secondary to retrograde flow in in the the ovarian ovarian vein are a recognized recogn ized cause of chronic pelvic pelvic pain pain (3). Although the syndrome is less appreciated ated than than the corresponding entity in men, men , it has been given given the the term "pelvic congestion syndrome." The resulting ing symptom symptom complex includes incl udes varying degrees of pelvic pain worse ning after long periods of standing pain typically typically worsening or or at at the the end of the th e day, labial varicosities, and dyspareunia reunia (which (which may be at the time of o f sexual intercourse or, rypica lly, immediately after). Many women note or, more more typically, varicose veins in their legs, which may recur recu r after recurrent rent surgical surgica l procedures. Like retrograde flow in the gonadal vein in men, Like critica l analysis of the disorder and its treatment are critical difficult because pelvic varicosities are seen in many difficult nu merous asymptomatic women and because there are numerous asymptomatic causes of chronic pelvic pain. In addition, it is unusual causes for pelvic pelvic venous ectasia to develop after pregnancy; for however, in "physiologic" "physiologic" venous ectasia, blood flow is however, ante grade. Any patient considered to be a candidate candid ate for antegrade. this disorder disorder should have the benefit of gynecologic gy necologic this and laparoscopy to exexamination, pelvic ultrasound, examination, pelVic clude pelvic infectio us disease, tumors, or endometrioclude pelvic infectious sis, before before ovarian venography. venography. sis, Ova ria n venograp hy is performed perfonned in the same manOvarian venography ner as as venography of the spernlatic spennatic veins ve ins with w ith the exner ce ptio n that, if the patient patien t has retlu''( reflu.'{ sufficient to cause ca use ception pelV iC pain, pa in, itit will be obvious with left renal vein or pelvic proximal right right ovarian vein injection. There is no need to to prOXimal overcome compercnt competent valves. If ovarian vein reflux reflu x is overcome confirmed in a patient with w ith the appropriate clinical conftrmed symp toms, retrograde flow can be interrupted by surgisymptoms, cal ligation ligation (4) or by embolization embo lization (5-7), with w ith cure or cal sym ptomatic improvement rates of 73% and 78%, resymptomatic spectively, reported. This com pares with reported imspectively, compares p rovement o f 66% in women with pel ViC congestion provement of pelvic afte r bilateral oophorectomy and hysterec· hysterecsyndrome after syndrome tomy with with subsequent hormone replacement (8). Laparomy roscopic ovarian ovaria n vein vein ligation liga tion has also been described roscopic (9), alth01..Jgh although no large series has been reported to date. (9), Preprocedure diagnosis with ultrasound has been rePreprocedure ported (7); (7); however, however, in in this this author's author'S experience, experience, this this has poned has been disappointing in prospecti vely predicting patient", been disappointing in prospectively predicting patients with ovarian ovaria n vein vein reflux. reflux. with

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Indications ovarian venography and and embo embolization Indications for ova rian venography lizatio n include: pelVic pain. All All women women must must a. Unexplained chronic pelv ic pain. taparoscopy and pelvic pelvic ultrasound ultrasound to Io exexundergo laparoscopy pathologies. Lack of abnormal vascuclude other patho logies. Lack of abno rmal vascll lature at either of of these studies studies does does not not ppreclude reclude on venogravenograreflux on the possibility of ovarian vein reflux phy. extremity varicose veins immedia immediately recurb. Lower extremiry tely recurafterr adequa adequaee surgical treatme treatment. te surgical nt. rent afte C.

varicosities. These These are are vel)' very Severe labiaVperineal varicosities. and conserva conservative lherapy shou should difficult to treat, and tive therapy ld intervention underalways be contemplated. If interven tion isis underovarian vein refl reflux, like taken, and the patient has ovaria n vein ux, like these will will recur recur lower extremity varicose veins, these immediately the ovarian ovarian vein vein immedia tely after sclerosis unless the column" interrupted surgically surgically or or unun"pressure colu mn" is interrupted der radio radiologic guidance. logic gUidance.

Venography and and Technique of Ovarian Venography Embolization Ovarian performed on on aa tilt tilt table table Ova rian venography is best performed head elevaled elevated at least least 45 45 degrees. degrees. with the patient's heael

TransJemoral Trans/emoral Route A catheter is directed into the peripheral peripheral left left renal renal vein. vein. A left renal venogram is obtained obtained with wilh the the patient patient perperforming a Valsa lva maneuver. If there is no reflux into Valsalva there is no reflux into the ovarian vein vein,, and the ovarian vein clearly clearly arises arises from from the ehe rena renall vein, it is considered a negative negative study. study. Selective Selective ovarian venography to ddetect etect reflux in nondilated nondilated veins veins is not necessary in our experience. If If there there isis ovarian ovarian pacifi cation of pelvic ve in reflu vein refluxx and oopacification pelvic varicosities, varicosities, the the catheter is then advanced into into the dista distall porrion porrion of of the the rceful injection, left forceful injection, with with the lhe patient patient lefl ovarian vein and fo remaining upright and petforming lsa lva maneuver, performing a Va Valsalva maneuver, is performed lO ral channels. ItIt has 1O identify all collate collateral has not not been defined whether reflux into the the ovarian ovarian vein, vein, whethe sua lization of whetherr dilated or not, not, withou withoutt actual actual vi visualization of varicosities in pelvis can be a source of of pain. pain. If If varicosvaricosities are opacified, the catheter is then then directed directed as as far far cau dal as possible into each of the major major branches, branches, and and caudal emboli zation of the main an vein embolization main ovari ovarian vein and and all all visible visible co lla teral channels with glu e, tetradecyl sulphate, collateral glue, terradecyl sulphate, or or GiGiantu rco coils is performed, extending back to within anrurco extending back to within 22 cm em of the ovarian vein origin. Although Although there there is is no no difference in the initial ddinical inical response to emboli za tion response to embolization between different embolic agents, it seems seems logical logical that that embolization with a Jiquid might usion of of the the might effect effect occl occlusion revent recurrence. mo re distal varicosities and thereby pprevent recurrence. more However, this has never been proven. proven. The The catheter catheter isis then exchanged for a Simmons 11 nt II cathete catheterr oorr equivale equivalent and rian vein. and directed directed into into the the right right ova ovarian vein. Right Right ovarian ovarian venography needed, embolization embolization are are performed performed venography and, and, if if needed, in the same fash ion as described for the left. in the same fashion as described for the left.

Transjugular Route Under ultrasound guidance, a sheath is introduced into the left internal jugular vein. The sheath is used for patient comfort dUring the procedure. A catheter, usually a multipurpose shape (primary curve only), is positioned in the peripheral portion of the left renal vein. Renal venography, selective ovarian venography, and embolization are perfonned with use of the same diagnostic criteria and methods as described for the transfemoral route. The multipurpose shape catheter is used to perfonn the right ovarian venogram with no catheter exchange required. If the ovarian venograms are negative, bilateral internal iliac venograms are obtained, as rarely isolated pudendal vein reflux will cause symptomatic pelvic valicosities.

References 1. Robinson]C. Chronic pelvic pain. Curr Opin Obstet Gynecol 1993; 5:740-743. 2. Kames LD, Rapkin A], Naliboff BD, Afift 5, FerrerBrechner T. Effectiveness of an interdisciplinary pain management program for the treatment of chronic pelVic pain. Pain 1990; 41 :41-46. 3. Hobbs ]T. The pelvic congestion syndrome. Practitioner 1976; 216:529-540 4. Rundqvist F, 5andhold IE, Larsson G. Treatment of pelvic varicosities causing lower abdominal pain with extraperitoneal resection of the left ovarian vein. Ann ChiI' Gynaecol 1984; 2:946-951. 5. Machan L5, Fry PF, Doyle DL. Treatment of the pelvic congestion syndrome by ovarian vein embolization. (in press) 6. Capasso P, Simons C, Trotteur G, Dondelinger RF, Henroteaux D, Gaspard U. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol 1997; 20:107-111. 7. Cordis PR, Eclavea A, Buckley P], DeMaioribus CA, Cockerill ML, Yeager TO. Pelvic congestion syndrome: early clinical results after transcatheterovarian vein embolization.] Vasc Surg 1998; 28:862-868. 8. Beard RW, Kennedy RG, GangaI' KF, et al. Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion. Br] Obstet Gynaecol 1991; 98:988-992 9. Takeuchi K, Mochizuki M, Kitagaki 5. Laparoscopic varicocele ligation forpelvic congestion syndrome. Int] Gynaecol Obstet 1996; 55:177-178. 2:30 pm

Uterine Fibroids: Basic Concepts and Medical Management Charles C. Coddington, MD Denver Health Medical institute Den.ver, Colorado The u e of medical therapy for uterine fibroids is an approach that has a great deal of appeal because of the

relative ease compared to surgery. This comment does not include personal aspects of discomfort and length of postoperative recovery. Indications for therapy would be similar to surgical intervention and would center around preselving fertility potential or an individual's desire to maintain her uterus. Discussion of this option does not preclude definitive therapy which at the present time would involve a surgical modality and will be discussed in another section. The decision to maintain the uterus may be addressed as an aspect of age, but with grandmothers carrying and delivering their grandchildren or a 60-year-old delivering a child through donated oocytes, age becomes quite relative. One must also address cultural norms-a woman who has her uterus removed and becomes amenorrheic is considered "old" in some areas of the world. Aspects of symptoms must be clearly addressed so that bleeding can be described and a determination of the medical necessity may be made. Also, other factors such as abdominal pain, pressure, effect on bowel and bladder function must be accessed. Irregular vaginal bleeding is by far the most conunon complaint (30%) from patients (1). From a careful history, other organ involvement may be elicited and evaluated. The examinations which may be performed other than the physical examination are ultrasound and possibly MRI. Through these assessments, the size and consistency of fibroids may be determined. The importance of these assessments may help clarify if there is lateral pelvic wall compression of the ureters and hydronephrosis or increased vascular patterns in the suspected myomas which, in fact, may not be a smooth muscle leiomyoma, but a collection of glands/stroma seen in an adenomyoma. There also may be confirmation of the number and size, although when there are more than five or so, delineation is difficult. Serial examinations may help the size and growth-rate monitoring, but symptoms seem in most cases seem to encourage the patient to use therapy. Symptoms need be evaluated as to their severiry so thaI iron therapy, endometrial biopsy, or other specialist evaluation may be incorporated into the treatment plan. Rapid increase in size (increasing 2-4 weeks by examinations done 2-3 months apart) has been thought to be associated with malignancy but this does not seem to be the case as the rate may be 0.6%-1% (2).

However, after these evaluations, if the patient has decided on therapy, the approach will be how medical therapy can be used. If there is irregular bleeding and our biopsy is normal/negative, hormonal cycling such as birth control pills or medroxyprogesterone acetate can be implemented. Reports suggest that most patients will not show an effect of these ora I hormones on the growth of their myomas. 1n fact, myomas have been noted to decrease in size by 46% (3). In many cases, the oral hormones may help the bleeding. Another report also supported no association between fibroids and oral contraceptive use in ever:never users was RR-l.1 (With 95%

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