Pelvic Venous Disorders

Mark H. Meissner, MDPeter Gloviczki Professor of Venous & Lymphatic Disorders

University of Washington School of Medicine

Seattle, WA

Mark H. Meissner, MD

I Have No Disclosures Relevant To This

Presentation

Disclosure

The Current Status of Pelvic Venous DiseaseThe Alphabet Soup of “Syndromes”

Inaccurate diagnosis

Poor treatment outcomes

Denied reimbursement

Primary Pelvic Venous Disorders

Chronic Pelvic Pain• Pain

• Dysparunia• Dysuria

Pelvic Varices• Gluteal• Perineal• Vulvar

Four Clinical

Presentations

Leg Symptoms

• Pain• Swelling

Renal Symptoms• Flank Pain• Hematuria Internal Iliac

RefluxNutcracker Syndrome

Two Patterns of Reflux

Ovarian Vein

Reflux

Reflux Obstruction

Iliac Vein

Obstruction

“Pelvic Congestion Syndrome”

Chronic Pelvic Venous

Disorders≠

The Female Pelvic CirculationFour Interconnected Venous Systems

Great

Saphenous

SEV

Superfical

External

Pudendal

Deep External

PudendalInternal iliac tributaries

The “gateway” to the leg

Exactly analogous to perforating veins, connecting

The deep veins of the pelvis

The superficial veins of the leg

Pelvic Escape PointsKachlik D, Phlebology2010

The Venous “Reservoirs” of the Abdomen & Pelvis

The Pelvic Venous Plexus

Drained byThe Ovarian Veins

The Internal Iliac Veins

The Renal Hilar Plexus

Drained byThe Left Renal Vein

Hilar

Varices

The Lower Extremity

Hilar

Varices

Symptoms presumably related to reservoir distension

All reflux and obstruction occurs in 2 patterns

Uncompensated – No outflow from distal reservoir

Compensated – Collateral outflow from distal reservoir

Pattern determines symptoms

Pelvic

Reservoir

Renal

Reservoir

Leg

Reservoir

L Internal

Iliac Vein

L Ovarian

Vein

Pelvic Floor

L Renal Vein

Pelvic Escape

Points

Uncompensated Reflux

L Ovarian Vein

L Internal Iliac Vein

Compensated Obstruction

L Renal Vein

L Common Iliac Vein

Uncompensated Obstruction

L Renal Vein

L Common Iliac Vein

Compensated Reflux

L Ovarian Vein

L Internal Iliac Vein

Pelvic Venous Disorders – A New Paradigm

For now, refer to the primary underlying pathophysiology

1º L renal vein obstruction

1º or 2º (post-thrombotic) Iliac vein obstruction

1º Ovarian vein reflux

1º Internal iliac vein reflux

Clear need for a new classification instrument based on

Clinical presentation

Anatomy & physiology

Natural history

Treatment options

Pelvic Venous Classification

Pelvic Clinical

CategoryDescription

0 No clinical manifestations of venous disease

5 Chronic left flank pain of venous origin with or without hematuria

a Left flank pain

b Hematuria

3 Lower extremity edema of pelvic venous origin

4 Venous claudication

1 Non-cyclic chronic pelvic pain of venous origin

2 Pelvic origin lower extremity varices

• Currently in developmental phase

• Funding by SIR / ACP

• Further designation of etiology, anatomy, & pathophysiology

Pelvic ClassificationExamples

L Renal Vein

Compression w Chronic

Pelvic Pain

“Pelvic Congestion

Syndrome”

C1EPALRV(O),LOV (R)PR,O

Post-thrombotic

Venous

Claudication

C4ESALCIV.LEIVPO

Chronic Pelvic Pain

“Pelvic Congestion

Syndrome”

C1EPALOV,ROVPR

Conclusions

• 4 interconnected systems

• L renal vein

• Ovarian veins

• Internal iliac veins

• Great saphenous vein

• 2 abdominal-pelvic reservoirs

• The renal hilum

• The pelvis

Great Saphenous

SEV

Superfical

External

Pudendal

Deep External

Pudendal

• Symptoms related to reservoir distension

• “Syndrome” terms are imprecise and misleading

• Precise patient definition is needed

• Clinic presentation

• Anatomy

• Natural history

• Treatment response

• A discrimitive instrument, aligned with CEAP, is needed