R.L. Worthington-Kirsch, MD
Delaware Valley Imaging, Ltd.
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R.L. Worthington-Kirsch, MD Delaware Valley Imaging, Ltd. |
 Fig. 1. Ultrasound of the right labia shows vascular spaces with venous flow. |
 Fig. 2. Coronal MRA of the abdomen and pelvis shows dilatation of the left ovarian vein and varices in the pelvis. |
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A 52-year-old woman who works as an office manager for a gynecologist began to complain of chronic pelvic pain and "fullness" or a "lump" in the right labia. The pain is worse at the end of the day and when the patient sits. She noted that the abnormality of the labia was more prominent when she was erect. She was examined by her employer, who told her there was no abnormality. He refused to examine her in any position but the standard supine lithotomy position. A second gynecologist diagnosed obturator internus spasm and referred her for Physical Therapy. A third gynecologist found a nodule in the labia and told the patient it was a sebaceous cyst and should not be operated upon. A fourth gynecologist asked for an ultrasound examination of the labia after palpating the abnormality. The ultrasound with color flow (Figure 1) showed dilated vessels with venous flow. MRA of the pelvis (Figure 2) showed a tortuous, dilated left ovarian vein with multiple varices in the pelvis. The patient was then referred for ovarian venography. The procedure was done from the right internal jugular venous approach. Injection of the left renal vein with the patient semi-erect (Figure 3) shows free reflux of contrast down a dilated ovarian vein to the level of the broad ligament with varices in the pelvis. After advancing the catheter into he pelvis, injection showed the varices more clearly, and demonstrated the varices in the labia (Figure 4). After embolization of the left ovarian vein with multiple coils there was no further flow into the pelvis (Figure 5). The right ovarian vein was then similarly catheterized and embolized. Questions: 1) Should I have separately punctured the labial varices and injected Gelfoam or thrombin? 2) Should I have embolized with a sclerosant instead of or in addition to coils? 3) "Pelvic Congestion Syndrome" is regarded as a controversial entity by many gynecologists (because of its use in the 40s and 50s as an excuse to sterilize women). When I discuss this entity, I refer to it as "Ovarian Vein Syndrome." Are there other suggestions for raising the awareness of our gynecologic colleagues regarding this disease? 4) It would be very helpful to have a large series of these patients with mid to long-term follow-up presented (better yet, published). The smaller reports available indicate that the response rate to ovarian vein embolization is 75-80% and that symptom relief is durable. What experience and outcomes do you have with this entity and its therapy? |
 Fig. 3. Left renal venogram shows dilated ovarian vein with no functioning valves and free reflux to the pelvis. A normal ovarian vein is 2-3mm in diameter and have functional valves. Note also the large retroperitoneal collateral from the renal vein to the mid section of the ovarian vein.
Fig. 4. Injection of the caudad portion of the left ovarian vein fills varices throughout the pelvis, and also fills varices in the labial region.
Fig. 5. Injection of the left renal vein with the patient semi-erect after coil embolization of the ovarian vein. Note that the collateral seen previously does not fill. |
| Related Cases:
Case 797_10 -- Ovarian vein embolization |
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