Advances in the diagnosis and management of pelvic stasis syndrome
Pelvic stasis syndrome is a clinical syndrome with chronic pelvic pain as the main symptom based on pelvic varicose veins stasis, which was first described by Taylor in 1949 as a summary of case data and description of etiology, pathology, pathophysiology, clinical manifestations and prevention, so it is also called Taylor syndrome [1]. Because there are few positive clinical symptoms, the disease is not easily detected in those who have typical positive symptoms and are not sufficiently aware of the disease. The progress of the diagnosis and treatment of pelvic stasis syndrome in terms of imaging examination and treatment is described below.
I. Diagnostic criteria
The diagnostic criteria of pelvic stasis syndrome were formulated with reference to the New Practical Gynecology [2], Diagnostic Criteria for Gynecological Diseases [3] and the Guidelines for Clinical Research on New Chinese Medicines [4]. The main clinical manifestations:three pains (pelvic cramps, low back pain, painful intercourse), two more (more menstruation, more leucorrhea), and one less (less positive gynecological examination signs). The pain can sometimes radiate to the lower limbs, perineum and lumbosacral region with severe premenstrual tension and breast tenderness. Stasis of pelvic veins causes pain, probably due to compression of lymphatic vessels and nerve fibers by dilated and curved veins.
II. Imaging examination
When pelvic venous stasis is suspected clinically based on the history, or when varicose veins in the vulva or buttocks are found clinically, imaging examination is needed to clarify whether there is dilatation of deep pelvic veins.
(1) Transvaginal color Doppler flow imaging (CDFI): In patients with pelvic venous stasis, long oval liquid dark areas are detected in one or both adnexal areas, and some of them are worm-like tortuous folds and beribboned dark areas, which are dilated veins.
(2) Pelvic ultrasonography: the sonographic changes of pelvic venous stasis show different morphology, width, and alignment of echogenic areas in the lower part of the fallopian tubes or the broad ligament of the uterus bilaterally or unilaterally, showing earthworm-like or network-like changes, with the widest echogenic area being 1.5 cm and the narrowest 0.4 cm [6].
(3) Pelvic venography: with reference to the X-ray diagnostic criteria proposed by EI-Minawi et al [7] and Wang Zhenhai et al [8], it is mainly based on the alteration of pelvic vein hemodynamics and morphology, the length of contrast contouring time, and the appearance of abnormal collateral circulation as classification criteria for the diagnosis of pelvic stasis.
(1) Normal: After contrast injection, the veins of the myometrium appear to be shaded by reticular structures, so that the shadow of the uterine contour shows clearly, the ovarian veins and uterine veins are uniform in thickness, the walls are not dilated and distorted, and all the contrast is contoured in the veins within 20 seconds.
(2) Mild: thickened and tortuous uterine veins and ovarian veins, with a contouring time of 20-40 seconds.
(3) Moderate: thickened and tortuous uterine veins and ovarian veins, varicose veins or tumor-like changes in the pubic area, with a contouring time of 40 to 60 seconds.
(4) Severe: thickened and tortuous uterine and ovarian veins, varicose or tumor-like changes in the internal pubic veins, formation of abnormal collateral circulation and/or internal iliac veins, etc., with a contouring time of 60 seconds or more.
(4) Laparoscopic examination: the laparoscopy is performed according to the routine operation, when the laparoscope is inserted into the abdominal cavity, first of all, the pelvic veins are observed to be exposed, varicose or angered with tumor-like changes, and if there are the above changes, the site and scope are carefully observed, and then the examination bed is slowly shaken to form a hip-high and head-low position of 60 degrees, and at the same time, the uterus is plucked to make the uterus in forward flexion, and the disappearance of the veins revealed during and after this process is observed, and the disappearance time is calculated. The time of disappearance was calculated. The stasis vein reappears when the uterus is restored to the lying position and when the uterine device is stopped. Sometimes it is necessary to repeatedly shake the examination bed and change the position of the uterus to observe the pelvic veins. Based on the morphological changes of the pelvic veins under direct vision and the time of disappearance of the pelvic veins with the change of position and uterine position, laparoscopic diagnostic criteria for pelvic stasis were formulated and divided into three types: mild, moderate and severe.
1. Mild: The veins in one or both fallopian tube tracts and funnel ligaments were revealed in the horizontal position, and the revealed veins disappeared when the head was changed to a low-hip height of 60 degrees and the uterus was pivoted to an anteriorly flexed position.
2. Moderate: The varicose veins in the tubal ligaments and funnel ligaments on one or both sides in the lying position are earthworm-like, and the veins at the base of the broad ligament are exposed.
3. Severe: when the veins in the tubal ligament and funnel ligament are angered and tumor-like in one or both sides in the lying position, and varicose veins at the base of the broad ligament and parametrium are revealed, the angered veins gradually disappear in more than 20 seconds after changing to a head-low-buttock height of 60 degrees and toggling the uterus lifter so that the uterus is in forward flexion, but the varicose veins are still clearly seen [6].
(5) Pelvic hemogram. XL-l type hemogram and XDH-2 type ECG were used. The pelvic flow patterns (i.e., parapubic and caudal leads) on both sides were measured separately, and the patterns could be divided into normal and abnormal patterns. The abnormal waveforms in this disease accounted for 63, 6% of the cases, which were statistically significantly different from the normal pelvic flow graphics [6].
(6) Selective angiography. It is the most reliable diagnostic method. Venographic features of pelvic congestion include ovarian veins greater than 10 mm in diameter at their widest point (normal less than 5 mm), congested and dilated uterine veins, moderate or severe congestion of the ovarian venous plexus, and filling of vulvar and/or thigh veins with varicose veins. Treatment with ovarian vein embolization for pelvic vein stasis can be effective in relieving symptoms [9].
(7) Isotope pelvic blood pool scan. Radionuclide 113mIn is commonly used to detect local varicose veins in pelvic stasis. The blood stagnates into a “blood pool” and the radionuclide forms a concentrated area [10].
III. Treatment
Since the etiology and pathogenesis of pelvic venous stasis syndrome are unclear, there are various treatment methods, mainly including non-surgical and surgical treatment, which are summarized as follows.
1.General treatment
Let the patient pay attention to the combination of work and rest, avoid standing for a long time, eat less stimulating food, pay attention to the abstinence of sexual life, and sleep in prone position.
2.Drug therapy
(1) Symptomatic treatment: the trial of phytonomics, sedatives or muscle nutrients, such as glutamate, vitamin E, hydrochloric acid, galantamine, neostigmine, diazepam (Valium), etc., has a certain effect on reducing various chronic pain and improving sleep.
(2) Endocrine therapy with progesterone, danazol, contraceptives and GnRH analogs to inhibit ovarian function, which can completely relieve the symptoms after 6 months of treatment, but is prone to recurrence after stopping the drug [11]. Also, this disorder occurs in the reproductive age, and ovarian suppression throughout the reproductive period is inappropriate.
(3) Intravenous administration of vasoconstrictive drugs such as dihydroergotamine provides temporary relief of pain while the pelvic veins are constricted, which can be used in acute episodes of abdominal pain but has no lasting effect [12].
(4) Non-steroidal antipyretic and analgesic drugs were used, and 70% of patients had different degrees of pain relief during treatment.
3.Interventional treatment
Interventional treatment is transcatheter ovarian vein embolization therapy [19]. MaleuxG [20] recently reported 41 patients with pelvic vein stasis syndrome, all of whom were confirmed by pelvic venogram.
4.Surgical treatment
(1) Ovarian vein high ligation.
HobbsJT [22] started to perform open route bilateral ovarian vein ligation in patients with pelvic stasis syndrome in the 1980s, and most of the patients had different degrees of significant improvement in pain symptoms after the surgery, but the surgery was relatively more invasive. After the 1990s, with the development of laparoscopic technology, minimally invasive surgery has been widely used in the field of gynecology. The laparoscopic opening of the peritoneum at the pelvic funnel ligament, separation of ovarian arteries and veins, and ligation of one or both ovarian veins can achieve satisfactory results in patients with pelvic stasis syndrome, and MathisBV [23] was the first to report the successful treatment of this type of patients with laparoscopic techniques in the early 1990s.
(2) Laparoscopic suspension of the round ligament.
It is indicated for young patients with hypertrophied posterior uterus and who require preservation of reproductive function. Laparoscopic procedure: from the point where the round ligament enters the pelvic and abdominal cavity on one side, successive folding sutures are placed in the direction of the uterus until 2 cm from the uterine horn; then the sutures are returned once and the sutures are drawn tightly and knotted to correct the uterus to an anterior position. The contralateral round ligament was treated in the same way. Returning the posterior uterus to the anterior position often reduces the size of the hypertrophied uterine body, thus reducing or eliminating the symptoms of pelvic pain. This is due to the change of the uterus from posterior to anterior position, which reduces venous pressure and accelerates blood flow in the ovarian region of the uterus, thereby improving stasis [24]. Therefore, reducing the pelvic venous pressure is the main reason for improving pelvic stasis, and the posterior position of the uterus is an important factor in increasing the pelvic venous pressure, and factors such as long-term standing can aggravate the increase of venous pressure, so changing the position of the uterus is fundamental to the treatment of pelvic stasis syndrome.
(3) Transabdominal total hysterectomy and double adnexal resection.
Since this syndrome occurs mostly in young women and the uterus has many important endocrine and psychological roles in addition to being a reproductive organ, surgical removal of the uterus for this disease is indicated in women over 45 years of age. Liu Yusheng et al [25] concluded that adnexal resection alone is not effective, so total hysterectomy and one side of the adnexa is advocated. Wang Zhenhai et al [26] and Cai Guangzong [27] also advocated total hysterectomy in patients with severe pelvic stasis, and their results were satisfactory. Therefore, the varicose uterine veins and ovarian veins should be removed as much as possible during surgery.
(4) Broad ligament fascial repair.
It is suitable for young and severe pelvic stasis syndrome due to laceration of the broad ligament. However, the patient after surgical repair should choose the cesarean delivery method for another pregnancy, otherwise the repair can fail.
5.Comprehensive therapy.
Integrative therapy includes pain control, functional restoration, and improved pain coping skills are superior to pharmacotherapy in reducing pain and somatic symptoms. Integrative therapy integrates medical interventions, interventions for social and environmental problems, cognitive-behavioral strategies and treatment of psychological disorders into one, which is superior to isolated pharmacological or surgical therapies in terms of improving the patient’s pain level, overall health status and functional status.