CASE 8981 Published on 09.11.2010

Young woman with deep pelvic pain (ECR Case of the Day)

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Ros Mendoza L, Martínez E, Marín MA, Artigas JM.
Department of Radiology, Hospital Miguel Servet, Zaragoza, Spain.

Patient

14 years, female

Categories
Area of Interest Genital / Reproductive system female, Veins / Vena cava ; Imaging Technique Ultrasound, Ultrasound-Colour Doppler, Ultrasound-Power Doppler, CT
Clinical History
We present the case of a 14 year old woman, with intermittent deep pelvic pain for 4 months. There were no antecedents of interest.
Imaging Findings
Figure 1: Sagittal conventional grey-scale US scan of the pelvis shows normal uterus and urinary bladder. There is a fluid-filled bowel loop in a retrouterine location mimicking peritoneal fluid.
Figure 2: Transversal conventional grey-scale US scan of the pelvis shows normal uterus and tortuous, microcystic-like structures in a both parauterine areas.
Figure 3: Transversal US scan slightly caudal to Fig 2 demonstrates an anechoic, left paraovarian, tubular structure. The bowel loop described on Fig 1 is also present here in a right, retrouterine location.
Figure 4: Transversal US colour-Doppler examination of the pelvis demonstrates bilateral tortuous vascular venous structures located in parauterine areas, corresponding with hypoechoic images seen in grey-scale US examination.
Figure 5: Transversal US power-Doppler examination (same level than Fig 3) clearly shows tortuous ovarian and parauterine vessels.
Figure 6: Sagittal US power-Doppler scan of the left adnexal zone confirms the presence of parauterine and ovarian varices.
Figure 7: Helical CT scan after IV contrast-medium administration confirms bilateral parauterine varices. Both studies CT and US were performed the same day.
Figure 8: Transverse contrast-enhanced abdominal CT scan shows engorgement of the left ovarian vein.
Discussion
Venous drainage of the ovaries occurs via the ovarian plexus, which communicates with the uterine plexus in the broad ligament. The ovarian veins arise from the parauterine venous plexus and ascend along the psoas major muscle, entering the inferior vena cava on the right or the left renal vein on left side. Belenky et al [1] found a near 10% prevalence of ovarian varices in the general population and more than half of these patients were symptomatic. Dilated ovarian veins are frequently seen in parous women, but as an isolated finding is rarely associated with pelvic pain [2]. Pelvic varices consist of tortuous and dilated parauterine and ovarian veins and are usually bilateral. Paravaginal, broad ligament, pelvic sidewall, and internal iliac varicosities may also be present. The criteria proposed for the diagnosis of pelvic varices by CT or MR are: four or more ipsilateral tortuous parauterine veins of varying calibre at least one of which measuring over 4 mm, or an ovarian vein diameter >8 mm [3].
Pelvic varices may be primary or secondary. The aetiology of primary pelvic varices is unknown and organic (valvular deficiency, parity, hormonal vasodilatation, left renal vein entrapment syndrome) and psychogenic aetiological factors have been proposed. Primary pelvic varices are associated with the pelvic pain syndrome, although the two conditions can occur independently. Pelvic pain in female patients is one of the most frequent causes of outpatient visits to primary care physicians and gynaecologists. The pelvic pain syndrome is usually confined to women of reproductive age and its prevalence in the United States approached 15% in women of childbearing age [2-4]. Secondary causes of pelvic varices include inferior vena caval obstruction, portal hypertension, increased pelvic blood flow and vascular malformations. Secondary pelvic varices are rarely associated with pelvic pain [3].
Ultrasound is the first imaging modality in the study of pelvic pain. CT and MR imaging may be performed when US findings are equivocal [5]. Differential diagnosis of pelvic varices on conventional US studies include: pelvic adenopathy, solid adnexal masses or ovarian cysts. Transabdominal or transvaginal Doppler ultrasound are useful to distinguish varices from cystic adnexal masses by demonstrating venous blood flow within varices. Arteriovenous malformations may occur in uterus or parauterine tissues. They usually show presence of arterial flow on Doppler US studies and an early enhancing mass-like lesion on CT and MRI examinations [3].
Differential Diagnosis List
Primary pelvic varices
Polycystic ovary syndrome
Bilateral pelvic adenopathy
Secondary pelvic varices
Pelvic arteriovenous malformation
Final Diagnosis
Primary pelvic varices
Case information
URL: https://www.eurorad.org/case/8981
DOI: 10.1594/EURORAD/CASE.8981
ISSN: 1563-4086