Chronic Pelvic Pain Attributable to Pelvic Congestion Syndrome: A Case Series

Chronic pelvic pain (CPP) is a common, multifactorial condition that is often misdiagnosed. First described in ancient Egypt, CPP was linked in the 19th century to pelvic venous insufficiency, now known as pelvic congestion syndrome (PCS). PCS caused by congenital venous anomalies (primary) or secondary insufficiency and outflow obstruction is a specific, reversible, and underrecognized subset of CPP.

We retrospectively reviewed medical records from 2019 to 2024 and selected 3 women with longstanding CPP unresponsive to conventional treatments. All underwent systematic evaluation, including exclusion of common gynecologic and gastrointestinal causes, vascular imaging, and comprehensive assessment.

All 3 patients were ultimately diagnosed with PCS secondary to venous outflow obstruction, including iliac vein compression syndrome (IVCS) and Nutcracker syndrome (NCS) with Symptoms-Varices-Pathophysiology (SVP) classification. Following endovascular treatment with balloon angioplasty, iliac vein stenting, and when indicated, ovarian vein embolization, all experienced immediate and sustained symptom relief. Long-term follow-up demonstrated durable outcomes without recurrence.

This case series underscores the importance of systematically evaluating CPP to accurately identify its underlying cause, particularly vascular etiologies such as secondary PCS due to venous outflow obstruction. Recognizing these treatable causes can prevent unnecessary interventions, alleviate prolonged suffering, and guide effective management strategies.