The evaluation of venous origin chronic pelvic pain: survey of current practice

Purpose: There is no consensus on the evaluation of women with presumed venous origin chronic pelvic pain (VOCPP). A survey of vascular specialists was performed to assess current practice.

Materials and Methods:

A survey was internationally distributed through IR and vascular societal contacts, assessing current practice for managing VOCPP. The survey was open from June to July 2024.

Results:

225 responding physicians treat women with VOCPP. The average age of respondents was 59, with 77% male, and the majority greater than 15 years in practice. The respondents were from the United States (43%), Asia (17%), and Europe (16%). Their primary disciplines included vascular surgery (47%) and interventional radiology (38%). 

62% routinely consult gynecology prior to embolization. 57% obtain a visual analogue score and 13% obtain a generic quality of life score before treatment, as well as 42% and 18% respectively after treatment. Routinely, 28% assess the response to hormonal ovarian suppression or flavonoid treatment before considering intervention.

Pre-procedural pelvic imaging is done in 95% of cases before an already planned venogram/IVUS and typically includes combinations of CT (64%), transabdominal pelvic ultrasound (48%), lower extremity duplex (48%), transvaginal pelvic ultrasound (45%), and MR (30%). Typical evaluation for iliac vein obstruction (IVO) includes venography +/- IVUS (63%), CT (53%), transabdominal ultrasound (33%), and MRI (26%). Thresholds for nonthrombotic iliac obstruction considered significant enough to treat included >50% diameter reduction (17%), >60% diameter reduction (39%), >50% area reduction (31%), and other (13%).

Conclusion: Two thirds of vascular specialists will consult with a gynecologist and a third will try pharmacological therapy. A wide variety of pelvic imaging studies are used before endovascular management of VO-CPP and there is no consensus iliac obstruction threshold to indicate stent placement. Non-uniform patient selection and care identified in systematic review is seen in current practice and is an impediment to acceptance of embolization and stenting for VOCPP by non-vascular colleagues.