Instrumental diagnosis of pelvic congestion syndrome

Pelvic congestion syndrome (PCS) is a multifactorial medical condition that is characterized by the absence of specific symptoms, and therefore, it needs very precise imaging for an accurate diagnosis. Diagnostic techniques can be noninvasive (duplex ultrasound) or minimally invasive (magnetic resonance, CT, and phlebography). Duplex ultrasound is regarded as a first-line investigation for PCS because it is noninvasive, easily accessible, and inexpensive. This procedure provides essential hemodynamic information, and when combining transvaginal and transabdominal approaches, it could determine the presence of venous dilations, reflux, and compressions. Cross-sectional imaging techniques, such as CT or magnetic resonance scans, are often ordered for abdominal pain, which shows venous varices in the area of the uterus or the pelvis. CT can exclude other pelvic pathologies. In comparison with CT, magnetic resonance venography is superior due to the absence of radiation. Catheter-directed retrograde selective venography or phlebography is the "gold-standard" method for the diagnosis of pelvic venous pathology, in all the variations according to the need. Phlebography confirms the diagnosis and assesses the venous anatomy, especially the collateral venous systems, and it is useful when planning embolization and coil selection. In addition, this procedure is usually performed at the same time as the treatment, with consequent benefits for both patients and physicians. The correct diagnosis of PCS is essential when choosing a treatment option, especially due to the high number of underdiagnosed cases.