Pelvic pain of venous origin: diagnostic insights from transvaginal ultrasonography

Francine Freitas Fernandes; Isabela Rodrigues Tavares; Manuella Brandão Barreto Silva; Joana Storino; Fanilda Souto Barros; Nathalia Cardoso Oliveira; Dionésio Oliveira Coelho; Paulo Sérgio Cossi; Edward Araujo Júnior; Gustavo Yano Callado; Alexandre Freitas Teixeira Fernandes; Luciana Pardini Chamie

doi:10.14366/usg.25270

Ultrasonography > Volume 45(4); 2026 > Article

Fernandes, Tavares, Silva, Storino, Barros, Oliveira, Coelho, Cossi, Araujo Júnior, Callado, Fernandes, and Chamie: Pelvic pain of venous origin: diagnostic insights from transvaginal ultrasonography

Review Article

Ultrasonography 2026; 45(4): 325-341. https://doi.org/10.14366/usg.25270

Pelvic pain of venous origin: diagnostic insights from transvaginal ultrasonography

¹Department of Radiology, GEUS Clinic – Specialized Group in Ultrasound Imaging, Salvador, Brazil

²Department of Vascular Surgery, Prime Care Medical Complex, São Paulo, Brazil

³Department of Vascular Surgery, Hospital Mater Dei, Belo Horizonte, Brazil

⁴Department of Radiology, Fanilda Barros Institute, Vitória, Brazil

⁵Department of Vascular Surgery, NC Vascular Health, São Luís, Brazil

⁶Department of Vascular Surgery, Angiovascular Clinic, Salvador, Brazil

⁷Department of Radiology, Cossi Clinic, Vargem Grande do Sul, Brazil

⁸Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil

⁹Discipline of Woman Health, Municipal University of São Caetano do Sul (USCS), São Caetano do Sul, Brazil

¹⁰Albert Einstein Israelite College of Health Sciences, Albert Einstein Israelite Hospital, São Paulo, Brazil

¹¹Department of Medicine, Bahian School of Medicine and Public Health, Salvador, Brazil

¹²Department of Radiology, Chamie Woman of Image, São Paulo, Brazil

Correspondence to: Edward Araujo Júnior, PhD, Department of Obstetrics, Paulista School of Medicine, Federal University of Sao Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria São Paulo, SP, CEP 05089-030, Brazil Tel, Fax. +55-11-3796-5944 E-mail: araujojred@terra.com.br

*This submission is based on an educational exhibit presented at the RSNA 2024 annual meeting. Exhibit space number: OBEE-25. Awards at RSNA 2024: Certificate of Merit Award.

Received December 23, 2025 Revised April 6, 2026 Accepted May 29, 2026 Published online June 29, 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Chronic pelvic pain is a common clinical condition among women and accounts for up to 15% of gynecological consultations. Pelvic pain of venous origin is one of the main gynecological causes of chronic pelvic pain, accounting for 16%–31% of cases. Several imaging modalities can be used to evaluate pelvic venous disorders; among them, ultrasonography is a first-line method because it provides real-time anatomical and functional assessment of the pelvic veins. This article reviews pelvic venous anatomy, etiopathogenic mechanisms, clinical manifestations, and imaging findings associated with pelvic venous disorders. Using illustrative cases, this review emphasizes the role of transvaginal ultrasound in detecting pelvic varices, venous insufficiency, and morphological and functional abnormalities, thereby supporting accurate diagnosis and appropriate management.

Keywords: Chronic pelvic pain; Pelvic pain of venous origin; Pelvic congestion syndrome; Transvaginal ultrasound; Magnetic resonance venography

Key points

Chronic pelvic pain of venous origin is a clinically relevant condition that affects a significant proportion of the female population; however, it remains frequently underdiagnosed. This comprehensive review discusses key concepts in pelvic venous disorders, including pelvic venous anatomy, etiopathogenesis, risk factors, clinical manifestations, and imaging diagnosis. The present review emphasizes the diagnostic power of ultrasonography, with a particular focus on the role of transvaginal ultrasonography as a tool for evaluating pelvic varices, and other morphofunctional venous abnormalities.

Introduction

Chronic pelvic pain (CPP) is defined as noncyclic pain lasting longer than 6 months and arising from pelvic organs or structures [1]. It is a common complaint among women, accounting for approximately 10%–15% of outpatient gynecological consultations [2]. Because gynecological, urological, gastrointestinal, and musculoskeletal disorders can all contribute to CPP, the diagnostic process is often prolonged and frustrating for patients [3].

Among gynecological causes, pelvic pain of venous origin is the second most frequent etiology and accounts for approximately 16%–31% of cases [4]. This condition is second only to endometriosis and has an estimated prevalence of 10% among women of reproductive age [5].

Pelvic pain of venous origin typically presents as chronic noncyclic discomfort that worsens during menstruation and after prolonged standing or sitting. Deep dyspareunia is also frequent and often worsens after intercourse [6]. Richet first described pelvic varices in 1857 [6]. However, the association between pelvic varicosities and CPP in women was not established until 1949, when Taylor introduced the concept of pelvic congestion syndrome (PCS) [6]. More than half a century of isolated observations followed before advances in imaging enabled the development of formal diagnostic criteria and standardized classifications.

In 2021, the American Vein and Lymphatic Society recommended replacing traditional terms such as PCS, May–Thurner syndrome, and nutcracker syndrome with the broader term pelvic venous disorders (PeVD). This revised nomenclature was intended to better reflect the clinical spectrum of these disorders by encompassing multiple hemodynamic mechanisms, including reflux, thrombotic and nonthrombotic obstruction, and congenital anomalies, while recognizing that these mechanisms frequently overlap [7].

The Symptoms-Varices-Pathophysiology (SVP) classification system was introduced as part of this initiative. This system categorizes cases according to clinical symptoms, the presence of varices, and anatomical, hemodynamic, and etiological findings. By linking symptoms with venous anatomy and pathophysiology, the SVP framework supports clearer communication among specialists and may help generate more consistent clinical evidence [7]. Despite this conceptual restructuring and the marked increase in scientific output over the past decade, pelvic pain of venous origin remains underdiagnosed in clinical practice. Delayed recognition can substantially impair quality of life, and affected women may wait up to 7 years before receiving a definitive diagnosis and appropriate treatment [8].

Several imaging modalities are available for assessing PeVD, including ultrasonography, computed tomography venography (CTV), magnetic resonance venography (MRV), and catheter-directed venography with intravascular ultrasonography (IVUS). Among these modalities, ultrasonography is distinctive because it combines high spatial resolution with real-time hemodynamic evaluation [6,7,9]. Its ability to directly visualize the pelvic veins makes it particularly useful for identifying varices, reflux, and morphological abnormalities.

Because PeVD remains underrecognized, radiologists, gynecologists, vascular surgeons, and other specialists involved in the care of patients with CPP should be familiar with its venous anatomy, pathophysiological mechanisms, clinical manifestations, risk factors, and imaging findings. This article reviews these topics and focuses on the role of ultrasonography, particularly transvaginal ultrasound (TVUS), in identifying pelvic venous abnormalities.

Pelvic Venous Anatomy

The pelvic venous system consists of two interconnected and highly variable networks: visceral and parietal. The internal iliac veins and gonadal veins are the principal components of these networks (Fig. 1). Because these venous pathways are extensively interconnected, venous incompetence within the pelvis may involve a broader network rather than a single isolated vessel [10].

The internal iliac vein provides the main venous outflow pathway for the pelvis, draining the pelvic organs, gluteal region, perineum, and pelvic walls. Its major tributaries include the middle rectal, obturator, lateral sacral, and superior and inferior gluteal veins. When these tributaries are incompetent, varicosities may develop in multiple territories, including the uterus, vagina, bladder, rectum, vulva, perineum, and gluteal region (Fig. 2) [11–13].

The right and left gonadal veins usually follow asymmetric drainage pathways. The left gonadal vein drains into the left renal vein, whereas the right gonadal vein drains directly into the inferior vena cava (Supplementary Fig. 1) [13]. In the midabdomen, both veins course anterior to the psoas muscle and remain in direct contact with it. Their anatomy is highly variable, particularly in the number of trunks, interconnections, and drainage sites. In an anatomical study of 200 gonadal veins, Lechter et al. [14] reported one to six trunks arising from the distal third of the vein and gradually merging along the ascending course.

The left gonadal vein is 6 times more likely than the right gonadal vein to develop insufficiency, primarily because of compression within the aortomesenteric space [15,16]. In addition, approximately 15% of left gonadal veins lack valves altogether [17]. Both gonadal veins drain the uterus, ovaries, mesosalpinx, parametrium, and pampiniform plexus. These drainage pathways form an important anastomotic network that helps regulate regional venous pressure [7].

When the gonadal veins are insufficient, they are classically associated with periovarian, periuterine, and vulvar varices. They may also be associated with varicosities of the extrapelvic round ligament, which can mimic inguinal hernias (Fig. 3), and with atypical varices in the pudendal region and along the medial and posterior aspects of the thigh.

Pelvic escape points are collateral venous pathways that connect the intrapelvic and extrapelvic venous systems [18]. The main routes include the following (Fig. 4): Perineal points (60%–70%): clitoral, intermediate labial, and perineal veins [18]; Inguinal points (21%–36%): varices along the extrapelvic round ligament [18]; Gluteal points: superior and inferior gluteal veins, which may result in varices in the posterior thigh and sciatic nerve distribution [18]; Obturator points: pathways associated with varices of the perineum or medial thigh [19].

A detailed understanding of pelvic venous anatomy is essential for interpreting ultrasonographic findings in women with CPP of venous origin. Because the pelvic venous system is highly interconnected, abnormalities in one venous territory can influence both pelvic and extrapelvic hemodynamics (Table 1) [20,21].

Etiopathogenesis

The etiopathogenesis of pelvic pain of venous origin is multifactorial and involves anatomical, hormonal, genetic, and environmental factors. This complexity likely contributes to the heterogeneity of clinical presentations and to the variability in therapeutic response [1].

Pelvic venous reflux is one of the principal pathophysiological mechanisms underlying PeVD. It is characterized by dilation and incompetence of the ovarian veins, internal iliac veins, or other venous trunks (Fig. 5) [22]. Congenital abnormalities of the venous wall may contribute to abnormal vessel dilation, which can compromise valvular function and promote reflux [23].

This reflux mechanism is most common in multiparous women of reproductive age, particularly those between 35 and 45 years of age, in whom hormonal influences have a central role. Estradiol promotes vasodilation by stimulating nitric oxide production, whereas progesterone reduces venous tone and weakens valvular function. Together, these effects may increase susceptibility to reflux in pelvic veins, especially during pregnancy or after prolonged hormonal exposure [22,24,25].

Venous obstruction is the second major pathophysiological mechanism and is associated with extrinsic compression of central venous trunks. The most frequent causes are compression of the left renal vein between the aorta and superior mesenteric artery (Fig. 6) and compression of the left common iliac vein by the overlying right common iliac artery (Fig. 7) [25].

The reservoir model proposed by Meissner et al. [7] conceptualizes symptoms in terms of pressure redistribution across four main venous compartments: the left renal hilum, the pelvis, extrapelvic superficial veins, including the vulva, perineum, and medial/posterior thigh, and the superficial and deep veins of the lower extremities.

For example, compression of the left renal vein may cause flank pain and hematuria when collateral compensation is insufficient. Alternatively, if decompression occurs through the left ovarian vein, the same upstream obstruction may present as CPP. Similarly, reflux or obstruction in any venous compartment may be partially offset by collateral development, which redirects venous pressure to more caudal territories. As a result, different anatomical and hemodynamic abnormalities may produce similar symptoms, whereas similar lesions may produce different clinical manifestations depending on the extent and distribution of collateralization [7].

Psychosomatic dimensions should also be considered when evaluating patients with pelvic pain of venous origin. Studies have shown that up to 60% of affected patients have associated emotional disturbances, which may modulate pain perception and influence response to treatment [26,27]. These findings support a multidisciplinary approach that includes psychological assessment and care as part of the clinical management of PeVD.

Clinical Manifestations and Risk Factors

Pelvic pain of venous origin has variable clinical manifestations and often presents with nonspecific symptoms, which contributes to underdiagnosis. Recognizing risk factors and characteristic symptom patterns is therefore essential for guiding imaging evaluation and improving diagnostic accuracy [1,9]. Table 2 summarizes the main predisposing factors reported in the literature, including hormonal, obstetric, and familial factors commonly associated with primary forms of PeVD [1].

The most common manifestation is chronic noncyclic pelvic pain that worsens during menstruation, prolonged standing, or physical exertion. Deep dyspareunia is also common and often worsens after intercourse. Other frequent symptoms include perineal heaviness, low back pain, and urinary symptoms such as urgency. Table 3 summarizes the most commonly reported symptoms. These findings should be distinguished from the cyclic pain typical of endometriosis, which is highly prevalent and remains an important differential diagnosis [1,24,28].

Fig. 8 illustrates the anatomical-functional correlation between venous territories and predominant clinical manifestations. This integrated approach can help clinicians relate clinical signs and symptoms to hemodynamic abnormalities detected on imaging studies [4,22].

In a retrospective study of 132 patients, Herrera-Betancourt et al. [24] found that dysmenorrhea, visible vulvar varices, and tenderness over the ovarian points each had more than 80% sensitivity for diagnosing pelvic pain of venous origin. The combination of postcoital pain and ovarian point tenderness increased diagnostic sensitivity to 94%, with a specificity of 77%. However, pelvic varices alone do not establish a pathological diagnosis. Clinical symptoms must therefore be correlated with functional imaging findings to distinguish clinically relevant venous disease from incidental venous dilation [15].

Imaging Diagnosis

Imaging is central to the evaluation of PeVD. The main imaging modalities used in this setting are ultrasonography, CTV, MRV, and catheter-directed venography with IVUS [7].

Ultrasound

Several ultrasound protocols have been described for assessing PeVD, and approaches vary according to institutional expertise and anatomical focus [9,11,29,30]. Doppler ultrasound is generally considered the preferred initial examination because it is dynamic, widely available, and free of ionizing radiation. By allowing assessment in different patient positions and through multiple acoustic windows, Doppler ultrasound provides real-time hemodynamic information that improves the detection of venous abnormalities.

In clinical practice, the authors follow the protocol proposed by Barros et al. [30], which includes four complementary stages: transvaginal, transabdominal, transperineal, and lower-limb assessment. The TVUS stage is widely used in gynecological practice and is recognized as a first-line modality for investigating pelvic varices [11]. The examination is performed with a high-frequency endocavitary transducer (5–9 MHz), with the patient in the lithotomy position with the head of the bed elevated to at least 45° to promote venous filling. Close contact between the distal tip of the probe and the pelvic structures enables high-resolution B-mode and color Doppler imaging, allowing detailed assessment of venous plexus caliber, compressibility, and reflux. The examination is designed to identify periuterine and periovarian varices, evaluate the inferior segment of the gonadal veins, and assess the internal and external iliac veins. TVUS is also important for excluding alternative gynecological causes of CPP, particularly endometriosis.

Transabdominal evaluation is performed with a low-frequency convex transducer (2–5 MHz). This stage focuses on the cava–iliac axis and is used to assess renal and iliac venous compression, post-thrombotic changes, congenital anomalies, and the mid-to-superior segments of the gonadal veins (Supplementary Fig. 2).

Transperineal and lower-limb assessments are performed with the patient standing and with a high-frequency linear transducer (7–12 MHz). The transperineal approach evaluates communication between the deep pelvic venous system and extrapelvic superficial veins through pelvic escape points (Supplementary Fig. 3). Lower-limb imaging assesses the saphenous axis and identifies nonsaphenous varices of pelvic origin, which are typically located in the medial and posterior thigh, groin, gluteal region, or along the course of the sciatic nerve.

The protocol stages can be performed in any sequence without compromising diagnostic accuracy. In patients referred from gynecological settings, particularly those with CPP or suspected endometriosis, evaluation often begins with the transvaginal approach. If no specific gynecological pathology is identified but pelvic varices are present, the additional stages are recommended to determine whether the etiology is primary, due to venous insufficiency (Supplementary Fig. 4), or secondary, related to thrombotic or nonthrombotic obstruction. These stages also help assess downstream effects on the lower limbs.

In patients initially evaluated in vascular surgery settings, suspicion of pelvic-origin reflux typically arises when atypically located lower-extremity varices are identified. In these cases, additional ultrasound stages are used to identify escape points, determine which venous trunks are involved, and assess how these abnormalities affect the pelvic cavity.

Transvaginal Ultrasound

Technique

The cervix is first located in the transverse plane. The transducer is then angled toward the right and left paracervical regions to visualize the periuterine venous plexuses (Fig. 9). The gonadal veins are subsequently identified as they course laterally and superiorly toward the ovaries. The probe is then directed toward the lateral pelvic wall to identify the external and internal iliac veins. The external iliac vein is located anterolaterally, whereas the internal iliac vein lies posterolaterally.

Diagnostic criteria

After the periuterine and paraovarian venous plexuses are identified, the examiner must distinguish physiological venous anatomy from patterns suggestive of venous insufficiency. A venous diameter up to 5.0 mm is generally considered within normal limits. However, thresholds for pathological dilation vary across studies, with reported cutoff values ranging from 6.0 mm to 8.0 mm. In clinical practice, the authors preferentially use a threshold of 7.0 mm, although reflux may be present even in veins measuring less than 5.0 mm in diameter [4,31].

Hemodynamic evaluation with color and spectral Doppler during the Valsalva maneuver is essential for improving diagnostic accuracy. Classic bidirectional flow, or markedly increased antegrade-flow amplitude even without complete flow reversal, should be considered suggestive of reflux (Fig. 10) [4]. Although evidence remains limited, emerging data suggest that reflux lasting longer than 1 second in pelvic veins may be abnormal, similar to criteria used for the deep venous system, as proposed by Gavrilov et al. [32]. This criterion may also be applicable to the internal and external iliac veins.

Sonographic findings

Gonadal plexus insufficiency is the most common ultrasonographic finding in patients with pelvic varices. TVUS allows assessment of both gonadal vein diameter and hemodynamics. Reflux can be clearly demonstrated on color and spectral Doppler imaging (Fig. 11, Video clip 1) [30].

When feasible, the internal iliac veins should also be evaluated with TVUS because this approach provides higher resolution than transabdominal imaging [33]. Although systematic data are lacking, the authors’ clinical experience suggests that TVUS is more precise than the transabdominal approach for detecting intraluminal webs, caliber reduction, and mural irregularities in patients with post-thrombotic changes involving the iliac veins (Figs. 12, 13).

Pelvic vein dilation on TVUS does not always represent primary venous insufficiency. In some cases, dilated pelvic veins reflect collateralization due to caval or iliac vein thrombosis. In these situations, spectral Doppler typically shows no reflux during the Valsalva maneuver, which helps distinguish secondary varices caused by venous obstruction from primary insufficiency, in which reflux is expected (Fig. 14).

TVUS is also useful in the evaluation of acute pelvic pain. Although common causes include ovarian torsion and ruptured cysts, less common etiologies such as pelvic vein thrombosis should be considered after these conditions have been excluded (Fig. 15). Thrombosis in atypical sites or small-caliber pelvic veins should prompt evaluation for vascular malformations and thrombophilic conditions, because these findings may affect management [34].

Parametrial vein thrombosis is less frequently observed but may have clinically significant implications when detected on TVUS. Its identification can alter therapeutic planning, particularly in high-risk patients. Routine parametrial evaluation is therefore recommended as part of the TVUS examination, especially in patients with cancer (Fig. 16) [35].

Despite its advantages, TVUS has inherent limitations. Its restricted field of view prevents adequate evaluation of extrinsic compression affecting the left common iliac or left renal veins, which requires complementary transabdominal imaging. Diagnostic accuracy also depends heavily on the examiner’s familiarity with the technique and with the hemodynamic criteria used to assess pelvic venous insufficiency.

Complementary Imaging Modalities

CTV provides excellent anatomical detail and is particularly useful for identifying abdominal venous compression (Fig. 17, Supplementary Fig. 5). However, it has important limitations, including exposure to ionizing radiation, which is especially relevant in younger women, and dependence on appropriate timing of image acquisition relative to contrast bolus administration. Physiological variation in pelvic venous return may also limit opacification of key venous segments [36].

MRV provides high-quality anatomical characterization of pelvic venous structures without radiation exposure. Dynamic magnetic resonance imaging with time-resolved magnetic resonance angiography/venography, typically performed with 3-second temporal resolution, can depict gonadal vein reflux [37]. However, both CTV and MRV are usually performed with the patient in the supine position, which limits functional assessment [38]. In this position, venous reflux may be inadequately demonstrated, whereas vascular compression may be overestimated because gravitational loading on the vessels is reduced (Fig. 18, Supplementary Fig. 6) [39].

Catheter-directed venography, particularly when combined with IVUS, is valuable for evaluating the abdominal and pelvic venous systems. It enables detailed visualization of the venous lumen, identification of iliac or renal vein compression, and precise pressure-gradient measurement. In complex cases, it also provides direct information for therapeutic decision-making [38].

CTV, MRV, and catheter-directed venography with IVUS should therefore be considered when ultrasound findings are inconclusive, technical limitations are present, or complex anatomical abnormalities are suspected. These modalities complement ultrasound by refining anatomical characterization, improving diagnostic confidence, and informing therapeutic planning (Fig. 19).

Conclusion

Pelvic pain of venous origin is common but remains underrecognized in conventional ultrasound protocols. This review emphasizes the need to incorporate evaluation of PeVD into routine ultrasonographic practice, particularly through transvaginal imaging. Failure to identify a venous etiology, either as an independent cause or in association with other estrogen-dependent conditions, contributes to diagnostic delay and inappropriate therapeutic decision-making. Coordinated care among radiology, gynecology, and vascular surgery is essential for effective, patient-centered management.

Author Contributions

Conceptualization: Fernandes FF, Storino J, Barros FS, Oliveira NC, Coelho DO, Cossi PS, Chamie LP. Data acquisition: Fernandes FF, Tavares IR. Data analysis or interpretation: Silva MBB, Barros FS, Araujo Júnior EA, Callado GY, Fernandes AFT, Chamie LP. Drafting of the manuscript: Fernandes FF, Tavares IR, Silva MBB, Oliveira NC, Araujo Júnior EA, Callado GY, Chamie LP. Critical revision of the manuscript: Storino J, Barros FS, Coelho DO, Cossi PS, Araujo Júnior EA, Fernandes AFT, Chamie LP. Approval of the final version of the manuscript: all authors.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Supplementary Material

Supplementary Fig. 1.

Normal gonadal veins along the abdominal course (https://doi.org/10.14366/usg.25270).

usg-25270-Supplementary-Fig-1.pdf

Supplementary Fig. 2.

Normal inferior vena cava, external and internal iliac veins, left renal vein, and left common iliac vein on B-mode and color Doppler ultrasound (https://doi.org/10.14366/usg.25270).

usg-25270-Supplementary-Fig-2.pdf

Supplementary Fig. 3.

Perineal escape point (https://doi.org/10.14366/usg.25270).

usg-25270-Supplementary-Fig-3.pdf

Supplementary Fig. 4.

Dilated left gonadal vein with reflux demonstrated on both transvaginal and transabdominal ultrasound (https://doi.org/10.14366/usg.25270).

usg-25270-Supplementary-Fig-4.pdf

Supplementary Fig. 5.

Extrinsic compression of the left common iliac vein (https://doi.org/10.14366/usg.25270).

usg-25270-Supplementary-Fig-5.pdf

Supplementary Fig. 6.

Left gonadal vein dilation (https://doi.org/10.14366/usg.25270).

usg-25270-Supplementary-Fig-6.pdf

Video clip 1.

Color Doppler transvaginal ultrasound (TVUS) demonstrating dilated and tortuous pelvic varices, with the most prominent vessel corresponding to the left gonadal vein, located superior to the ovary (https://doi.org/10.14366/usg.25270.v1).

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Fig. 1.

Transvaginal ultrasound evaluation of pelvic veins.

A, D, G. B-mode images show the left internal iliac vein, left gonadal vein, and left external iliac vein, respectively (arrows). B, E, H. Color Doppler images demonstrate normal venous flow in each vessel (arrows). C, F, I. Spectral Doppler images confirm physiological anterograde flow patterns. The asterisk indicates the left ovary (D, E).

Fig. 2.

Transvaginal ultrasound of pelvic varices in multiple locations.

A, C, E, G. B-mode images show perirectal varices, vesical varices along the bladder wall, multiple dilated and tortuous structures in the left adnexal region, and an enlarged intramyometrial vein measuring approximately 6.4 mm in diameter, respectively (arrows). B, D, F, H. Color Doppler images confirm venous flow in all locations, with increased flow during the Valsalva maneuver (arrows).

Fig. 3.

Round ligament varicosities in the left inguinal region evaluated with a high-frequency linear transducer.

A. B-mode image shows multiple anechoic, serpiginous tubular structures within the inguinal canal, consistent with round ligament varices (arrows). B. Color Doppler image demonstrates venous flow within the dilated structures, with a marked increase in amplitude during the Valsalva maneuver, consistent with venous insufficiency (arrows).

Fig. 4.

Diagrammatic representation of key pelvic venous escape points.

IP, inguinal point; OP, obturator point; IPP, intermediate perineal point; PP, posterior perineal point; GP, gluteal point.

Fig. 5.

Schematic illustration of pathological pelvic venous reflux.

Red arrows indicate reflux. RGV, right gonadal vein; LGV, left gonadal vein; RIIV, right internal iliac vein; LIIV, left internal iliac vein.

Fig. 6.

Schematic illustration of compression of the left renal vein between the superior mesenteric artery and the aorta, resulting in impaired venous outflow and renal venous hypertension.

Elevated pressure redirects blood flow, leading to retrograde drainage and dilation of the gonadal vein.

Fig. 7.

Schematic illustration of compression of the left common iliac vein by the overlying right common iliac artery and adjacent lumbar spine, shown in coronal and axial views.

Fig. 8.

Diagram illustrating venous involvement and corresponding clinical manifestations.

Fig. 9.

Color Doppler transvaginal ultrasound image showing the periuterine venous plexus (arrow), with preserved caliber and venous flow.

Fig. 10.

Spectral Doppler criteria for pelvic venous reflux.

A. Color Doppler transvaginal ultrasound (TVUS) image shows dilation of the pelvic veins. B. Spectral Doppler TVUS image shows bidirectional flow during the Valsalva maneuver, indicating reflux. C, D. Spectral Doppler TVUS images show a low-amplitude, phasic venous waveform at rest (C). During the Valsalva maneuver (D), the vein becomes dilated and flow amplitude increases, consistent with venous reflux.

Fig. 11.

Left gonadal vein insufficiency in a 42-year-old multiparous woman presenting with chronic pelvic pain.

She was referred by her gynecologist for ultrasound evaluation of suspected endometriosis. A. B-mode transvaginal ultrasound (TVUS) image demonstrates a dilated left gonadal vein (arrow), measuring 8.7 mm in diameter. B. Color Doppler TVUS image shows retrograde venous flow in the left gonadal vein (arrow). C. Spectral Doppler TVUS image obtained during the Valsalva maneuver shows continuous retrograde flow, consistent with left gonadal vein insufficiency.

Fig. 12.

Post-thrombotic changes in the left iliac venous segment in a 34-year-old woman (G1P1A0) referred by a vascular specialist for evaluation of chronic pelvic pain.

Ten years earlier, while taking oral contraceptives, she experienced acute pain and swelling in the left lower extremity, leading to a diagnosis of iliofemoral deep vein thrombosis. A. B-mode transvaginal ultrasound (TVUS) image shows an echogenic intraluminal web within the left internal iliac vein (LIIV) (arrow), consistent with post-thrombotic changes. B. Color Doppler TVUS image shows spontaneous retrograde venous flow in the LIIV (arrow). C. Spectral Doppler TVUS image of the LIIV shows spontaneous retrograde flow, consistent with previous common iliac vein compression and prior deep vein thrombosis. D. B-mode TVUS image shows an intraluminal web within the left external iliac vein (LEIV) (arrow), consistent with post-thrombotic changes. E. Color Doppler TVUS image of the LEIV shows retrograde flow (arrow). F. Spectral Doppler TVUS image of the LEIV obtained during the Valsalva maneuver shows a retrograde flow pattern (arrow). G. Color Doppler transabdominal ultrasound image demonstrates compression of the left common iliac vein (white arrow) by the overlying right common iliac artery (black arrow). H. Color Doppler transabdominal ultrasound image shows the left external iliac vein (white arrow) and artery (black arrow), with caliber reduction and reversed flow during the Valsalva maneuver. Note the large collateral vein in the abdominal wall (black asterisk). I. Color Doppler ultrasound image obtained with a linear transducer demonstrates spontaneous reversed flow in the left epigastric vein (arrow), consistent with collateral drainage due to post-thrombotic changes in the left iliofemoral venous segment.

Fig. 13.

Post-thrombotic changes in a 53-year-old multiparous woman with a history of left common iliac vein compression.

The patient presented with chronic pelvic pain associated with left lower-extremity symptoms, including swelling, pain, and heaviness. A, B. B-mode transvaginal ultrasound (TVUS) images demonstrate intraluminal webs within the left external iliac vein (LEIV) (A) and left internal iliac vein (LIIV) (B) (arrows), consistent with post-thrombotic changes. C. Color Doppler TVUS image reveals spontaneous retrograde venous flow in the LIIV (arrow). D. Spectral Doppler TVUS image of the LEIV obtained during the Valsalva maneuver shows a retrograde flow pattern (arrow). E. Spectral Doppler TVUS image of the LIIV demonstrates spontaneous retrograde flow, consistent with sequelae of prior deep vein thrombosis (arrow).

Fig. 14.

Left iliac vein and graft thrombosis with pelvic collateral circulation and abdominal wall varices in a 40-year-old nulliparous woman with chronic pelvic pain.

She had a history of right nephrectomy and inferior vena cava graft reconstruction for paraganglioma. Thrombosis of both the graft and the left iliac vein subsequently developed, resulting in extensive pelvic venous collaterals and abdominal wall varices. She was referred for ultrasound evaluation. A. B-mode transabdominal ultrasound image demonstrates absence of the right kidney. B. Color Doppler transvaginal ultrasound (TVUS) image shows spontaneous venous flow in pelvic collateral veins at rest. C. Color Doppler TVUS image demonstrates reduced flow in the collateral veins during the Valsalva maneuver. D. Spectral Doppler TVUS image of pelvic collateral veins at rest shows continuous antegrade flow. E. Spectral Doppler TVUS image of the same collateral veins during the Valsalva maneuver demonstrates no evidence of reflux (arrow). F. Color Doppler ultrasound image obtained with a linear transducer demonstrates a collateral vein in the abdominal wall (arrow).

Fig. 15.

Right paravaginal vein thrombosis in a 32-year-old nulliparous woman.

She had a long-standing diagnosis of pelvic varicose veins and presented with sudden-onset right-sided pelvic pain after prolonged standing at work. Initial emergency department evaluation was unremarkable; however, targeted transvaginal ultrasound (TVUS) performed 15 days after symptom onset to assess the pelvic veins revealed subacute thrombosis of the right paravaginal vein. B-mode TVUS image demonstrates a hyperechoic, noncompressible structure within the right paravaginal vein (arrow), consistent with an intraluminal thrombus.

Fig. 16.

Periuterine venous plexus thrombosis associated with a uterine tumor in a 37-year-old nulliparous woman with chronic pelvic pain.

Transvaginal ultrasound (TVUS) revealed a uterine mass with right parametrial extension and thrombosis involving the adjacent periuterine venous plexus. A. B-mode TVUS image shows a well-defined, heterogeneous uterine mass involving the anterior wall, with regular margins and an internal cystic component (asterisk), suggestive of an adenomatoid tumor (dashed oval). B. Color Doppler TVUS image demonstrates internal vascularization within the lesion (asterisk). C. Color Doppler TVUS image confirms an echogenic thrombus within dilated right parametrial veins (arrow). D. Axial T2-weighted pelvic magnetic resonance image shows a uterine tumor with right parametrial extension (arrow).

Fig. 17.

Post-thrombotic changes of the left common iliac vein. Post-thrombotic changes of the left common iliac vein.

A. Coronal multiplanar reconstruction from contrast-enhanced abdominal computed tomography (CT) demonstrates a focal intraluminal filling defect in the left common iliac vein due to post-thrombotic changes resulting from extrinsic compression by the right common iliac artery (arrow). B. Three-dimensional volume-rendered CT image demonstrates prominent dilated collateral veins along the suprapubic abdominal wall (arrow).

Fig. 18.

Compression of the left renal vein.

A. Axial T2-weighted magnetic resonance venography image demonstrates narrowing of the left renal vein (asterisk) due to compression between the aorta (black arrow) and the superior mesenteric artery (white arrow). B. Coronal multiplanar maximum intensity projection image from contrast-enhanced magnetic resonance venography demonstrates compression of the left renal vein with associated dilation of the left gonadal vein (white arrow). Images courtesy of Karla Porto, MD.

Fig. 19.

Dilated left gonadal vein and pelvic varices treated with endovascular embolization.

A, B. Catheter venography images demonstrate a dilated left gonadal vein (white arrow) and pelvic varicose veins (black arrows in B). C. Catheter venography image demonstrates occlusion of the left gonadal vein by embolization coils (arrow). D. B-mode transvaginal ultrasound image demonstrates multiple hyperechoic structures within the left gonadal vein, consistent with embolization coils (arrows). Images A–C courtesy of Dionésio Coelho, MD.

Table 1.

Venous drainage pathways and anatomical distribution of pelvic varicosities

Venous trunk	Main tributaries	Main location of varicosities
Gonadal veins	Pampiniform plexus, mesosalpinx veins, uterine veins, parametrial veins	Periovarian region, periuterine region, vulva, inguinal round ligament, pudendal region, medial thigh, and posterior thigh
Left renal vein	Left gonadal, adrenal, and lumbar veins	Secondary reflux into the left gonadal vein and pelvic collateral plexuses
Internal iliac veins	Superior and inferior gluteal, lateral sacral, obturator, internal pudendal, and middle rectal veins	Uterus, vagina, bladder, rectum, gluteal region, and perineum
Pelvic escape points	Communicating branches of the pelvic veins, including pudendal, obturator, and gluteal branches	Vulva, perineum, inguinal region, gluteal region, medial thigh, and posterior thigh

Table 2.

Key risk factors for pelvic venous disorders

Risk factor
Premenopausal age
Multiparity
Hormonal disorders (e.g., elevated estrogen levels)
Pelvic venous anatomical anomalies
Family history of pelvic pain
Family history of venous disease
History of surgery for varicose vein correction or recurrence

Table 3.

Characteristic symptoms of pelvic pain of venous origin

Characteristic symptom
Noncyclic pelvic pain that worsens during menstruation
Dyspareunia, especially with postcoital exacerbation
Perineal heaviness
Pelvic pain associated with prolonged sitting
Pelvic pain associated with prolonged standing
Low back pain
Urinary urgency