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Case Reference No. CC-1298-03 The patient is 35 years old, Gravida 2, Para 2. She has suffered from chronic deep pelvic pain for over a year. She describes the pain as a "dull burning" or "pressure" in her pelvis. The pain is a little more prominent on the right side, and there is some radiation down her right leg. The pain does wax and wane somewhat, but does not consistently change with her menstrual cycle. She has had a few episodes when the pain was worsened after having sex. The patient has had four pelvic ultrasound tests in the last six months, as she has seen 5 different physicians during that time period, all for this problem. These have all been normal, and the gynecologists have told her that they could find nothing wrong with her. She then was sent to a gastroenterologist, who thought that she might have a mild form of Crohn's disease. He sent her for a CAT scan of the abdomen. The CAT scan was normal, except for the presence of tortuous vessels in the pelvis on both sides (Fig. 1). I called the referring physician and suggested that she have an ovarian venogram. This showed abnormally large, dilated veins in the pelvis (Figs. 2,3). Injection of the left ovarian vein fills vessels on the right side. Both ovarian veins were embolized with Gianturco coils. Three months later, the patient has had almost complete relief of her pain. She did have slightly worse than usual menstrual cramps the first period after the embolization, but since then she says that the pain is almost completely gone. This case is unusual in that the abnormal veins were visible on the CAT scan. In my experience, the abnormality is typically only demonstrable by venography. Unfortunately, most gynecologists do not think of this entity when they see chronic pelvic pain, at least in part because they can neither diagnose nor treat it.
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Questions: 1) How do you generate referrals for this and other relatively new procedures? 2) Should we be more active in encouraging our imaging colleagues to look for and report findings like this? 3) How often have readers suggested the diagnosis on the basis of pelvic CT or MRI findings (Ed.)? Related Cases: | ||
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