How Pelvic Congestion Syndrome Is Diagnosed: Tests, Scans and What to Ask

Getting a pelvic congestion syndrome diagnosis often takes time. The pain overlaps with many other conditions, routine scans are not set up to look at veins, and widened veins can be found in women who feel fine. There is no single test. Instead, doctors put together your story, an examination and the right kind of scan, while ruling out other causes. This guide walks through each step, explains why earlier tests may have looked normal and suggests questions to ask.

How is pelvic congestion syndrome diagnosed?

Diagnosis usually follows these steps:

1. Your history. The doctor asks what the pain feels like, where it is, how long you have had it and what makes it better or worse.
2. An examination. This includes the tummy, the pelvis and the legs and vulva for visible veins.
3. Tests to rule out other causes. For example, a pregnancy test, urine tests and swabs for infection.
4. Imaging of the pelvic veins. Usually a duplex ultrasound first, then CT or MR venography if needed.
5. A venogram, usually when treatment is being planned.

Care often involves a gynaecologist together with an interventional radiologist or vascular surgeon.

The history: what doctors listen for

Pelvic congestion syndrome is usually suspected from the pattern of the pain. Clues include:

• A dull, heavy or dragging ache, on one or both sides, lasting six months or more
• Pain that builds through the day or after standing, and eases when lying down
• A deep ache during sex or for hours afterwards
• Pain that flares around periods
• Having had children
• Varicose veins on the vulva, buttocks or upper inner thighs

Our page on pelvic congestion syndrome symptoms explains these in more detail.

The examination

A doctor may press gently on the lower tummy, where tenderness over the ovaries is common. They may also look for varicose veins on the vulva, buttocks and backs of the thighs, and do a pelvic examination to check for other causes. Because pelvic veins empty when you lie down, an examination on a couch can be completely normal even when the veins are the problem.

Pelvic congestion syndrome radiology: which scans are used?

Duplex ultrasound

A duplex ultrasound shows both the veins and the direction of blood flow. It is usually the first scan, because it is safe, widely available and uses no radiation. It is often done both through the vagina and through the tummy, so the scan can follow the ovarian veins up towards the kidneys.

How the scan is done matters. The veins fill and the backflow shows best if you are standing or tilted upright, or if you are asked to bear down (the Valsalva manoeuvre). A scan done only lying flat may miss the problem. Findings that suggest pelvic congestion include:

• Pelvic veins wider than about 4 to 5 mm
• An ovarian vein wider than about 5 to 6 mm
• Reflux, meaning blood flowing backwards down the ovarian vein
• Slow flow in the pelvic veins, and widened veins crossing the womb

Exact cut-offs vary between centres, and ultrasound results depend a lot on the skill of the person doing the scan. See pelvic vein ultrasound for how to prepare.

CT and MR venography

These scans use contrast dye to map the veins across the whole tummy and pelvis. They are good for showing widened veins, and for finding compression of the left kidney vein (nutcracker syndrome) or the left iliac vein (May-Thurner syndrome). MR venography avoids radiation and is often seen as the best non-invasive test. A drawback of both is that they are done lying flat, which can make veins look smaller than they are. More detail is in our guide to CT and MR venography.

Catheter venography

In a venogram, a specialist passes a thin tube into a vein in the groin, neck or arm and injects contrast dye while taking X-rays. It shows exactly which veins are widened and which way blood is flowing. Most specialists regard it as the reference standard, although at least one specialist clinic treats a careful duplex ultrasound as the main test. Because it is invasive, a venogram is usually done at the start of treatment, so faulty veins can be closed in the same session. Read about the pelvic venogram.

Why scans and laparoscopy can look “normal”

Many women with pelvic congestion have been told their tests are normal. There are good reasons for this:

• A routine pelvic ultrasound looks at the womb and ovaries, not the blood flow in the veins.
• Most scans are done lying down, when the pelvic veins drain and shrink.
• A laparoscopy is done lying flat, usually tilted head-down, with gas filling the tummy. All of these push blood out of the pelvic veins.
• CT scans for other reasons may mention widened veins only in passing, or not at all.

A “normal” result is still useful. It may have ruled out other causes. But it does not rule out pelvic congestion.

Widened veins are not always the cause

The reverse is also true. Widened pelvic veins and ovarian vein reflux are found in some women who have no pain, especially after pregnancy. So a scan finding alone does not prove the veins are causing your symptoms. A good assessment checks that the scan, the pattern of pain and the examination all point the same way before treatment is suggested.

Ruling out other causes

Pelvic pain has many possible causes, and more than one can be present. Doctors will usually consider:

• Gynaecological: endometriosis, adenomyosis, fibroids, ovarian cysts and pelvic infection
• Bowel: irritable bowel syndrome and constipation
• Bladder: bladder pain syndrome and urine infections
• Muscles and nerves: pelvic floor muscle tension, back or hip problems and nerve pain

Our guide to chronic pelvic pain covers these in more detail. A Singapore vascular surgeon’s article on symptoms and diagnosis gives another view of the same process.

The SVP classification, in plain words

Specialists increasingly describe pelvic vein problems with a system called SVP, published in 2021. It is a shorthand, rather like a postcode, that sums up three things:

• S for Symptoms. For example, kidney-area symptoms, chronic pelvic pain, or pain from veins outside the pelvis such as the vulva or legs.
• V for Varices. Where the widened veins are: near the kidney, inside the pelvis, or outside it on the vulva or legs.
• P for Pathophysiology. Which veins are involved, whether the problem is reflux or a blockage, and the cause, such as an old clot or compression.

You do not need to understand the codes. But if you see something like “S2 V2” in a letter, it simply means chronic pelvic pain with widened pelvic veins.

Questions to ask your doctor

• Will my ultrasound be done standing or with bearing down?
• Have other causes of my pain been ruled out?
• Do my scan findings match my symptoms?
• Is there any compression of the kidney or iliac veins?
• If I need a venogram, could treatment be done at the same time?

When the diagnosis is clear, see pelvic congestion syndrome treatment for the options.

When to see a doctor

See a doctor if you have had pelvic pain for months, pain that affects sex, work or sleep, or new varicose veins on the vulva or upper thighs. You can use our pelvic symptom check to organise your thoughts before an appointment.

Get urgent medical help for sudden severe pelvic or abdominal pain, heavy vaginal bleeding, fever with pelvic pain, fainting, or pain or bleeding when you might be pregnant. In Singapore, call 995 in an emergency.

This article is general information, not personal medical advice. Please speak to a doctor about your own symptoms. How we create our content.