Article

Identification of Pelvic Congestion Syndrome Using

Transvaginal Ultrasonography. A Useful Tool
Irene Valero 1 , Rocio Garcia-Jimenez 1 , Pamela Valdevieso 1 , Jose A. Garcia-Mejido 1,2 ,
Jose V. Gonzalez-Herráez 3 , Irene Pelayo-Delgado 4,5 , Ana Fernandez-Palacin 6, * and Jose A. Sainz-Bueno 1,2, *

1 Department of Obstetrics and Gynecology, Valme University Hospital, 3441014 Seville, Spain;
irevalarr@gmail.com (I.V.); rociogarji@gmail.com (R.G.-J.); Joseantoniosainz@hotmail.es (P.V.);
jagmejido@hotmail.com (J.A.G.-M.)
2 Department of Obstetrics and Gynecology, University of Seville, 3441014 Seville, Spain
3 Department of Angiology and Vascular Surgery, Valme University Hospital, 3441014 Seville, Spain;
jvgonzalezherraez@hotmail.es
4 Department of Obstetrics and Gynecology, Ramón y Cajal University Hospital, 3428042 Madrid, Spain;
ipelayod@yahoo.com
5 Department of Obstetrics and Gynecology, University of Alcalá de Henares, 3428803 Madrid, Spain
6 Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville,
3428803 Seville, Spain
* Correspondence: afp@us.es (A.F.-P.); jsainz@us.es (J.A.S.-B.)

Abstract: The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography
(VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative.
Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An





 observational prospective study including 67 patients was carried out. A TVU was performed
Citation: Valero, I.; Garcia-Jimenez, on patients, measuring pelvic venous vessels parameters. Subsequentially, a VG was performed,
R.; Valdevieso, P.; Garcia-Mejido, J.A.; and results were compared for the test calibration of TVU. Out of the 67 patients included, only
Gonzalez-Herráez, J.V.; Pelayo- 51 completed the study and were distributed in two groups according to VG results: 39 patients
Delgado, I.; Fernandez-Palacin, A.; belonging to the PCS group and 12 to the normal group. PCS patients had a larger venous plexus
Sainz-Bueno, J.A. Identification of diameter (15.1 mm vs. 12 mm; p = 0.009) and higher rates of crossing veins in the myometrium
Pelvic Congestion Syndrome Using
(74.35% vs. 33.3%; p = 0.009), reverse or altered flow during Valsalva (58.9% vs. 25%; p = 0.04),
Transvaginal Ultrasonography. A
and largest pelvic vein ≥ 8 mm (92.3% vs. 25%). The sensitivity and specificity of TVU were 92.3%
Useful Tool. Tomography 2022, 8,
(95% CI: 78.03–97.99%) and 75% (95% CI: 42.84–93.31%), respectively. In conclusion, transvaginal
89–99. https://doi.org/10.3390/
ultrasonography, with the described methodology, appears to be a promising tool for the diagnosis of
tomography8010008
PCS, with acceptable sensitivity and specificity.
Academic Editor: Emilio Quaia

Received: 18 October 2021

Keywords: pelvic congestion syndrome; chronic pelvic pain; transvaginal ultrasound; venography
Accepted: 27 December 2021
Published: 4 January 2022

Publisher’s Note: MDPI stays neutral

1. Introduction
with regard to jurisdictional claims in
published maps and institutional affil-
Pelvic congestion syndrome (PCS) is one of the existing causes of chronic pelvic pain
iations. (CPP) in women, which consists of the dilation and stasis of the pelvic venous plexus. CPP
is defined as the noncyclical pain in the hypogastric, lumbosacral, or perineal area, which
lasts 6 months or longer. It is quite an important health problem that causes up to 40% of
referrals for gynecology units [1,2].
Copyright: © 2022 by the authors. Currently, the diagnosis of PCS remains a challenge, given that there are not univer-
Licensee MDPI, Basel, Switzerland. sally accepted criteria for enlarged pelvic venous vessels. In recent years, the Symptoms–
This article is an open access article Varices–Pathology (SVP) classification has been published for pelvic venous disorders,
distributed under the terms and encompassing three domains: symptoms, varices, and pathophysiology, while also includ-
conditions of the Creative Commons ing the anatomy of abdominal and pelvic veins associated with hemodynamic anomalies
Attribution (CC BY) license (https:// and etiology. This instrument, once validated, could help to obtain homogeneous study
creativecommons.org/licenses/by/
groups with unified diagnostic criteria [3].
4.0/).

Tomography 2022, 8, 89–99. https://doi.org/10.3390/tomography8010008 https://www.mdpi.com/journal/tomography

Tomography 2022, 8 90

In addition, it is estimated that up to 15% of women between the ages of 20 and

50 years have varicose pelvic veins, although not all of them are symptomatic [4–6]. Most
authors claim that the gold standard for the diagnosis of PCS is venography (VG) [2,7–9].
However, in recent years, some authors have proposed the use of computerized axial
tomography (CT), magnetic resonance imaging (MRI), or transabdominal and transvaginal
ultrasonography as alternatives [7,10,11]. CT and MRI imaging allow for an extensive view
of the various causes of pelvic venous dilation, allowing us to use the SVP classification
while also being able to detect additional findings such as the nutcracker syndrome or May–
Thurner syndrome, which have therapeutic implications [3,12]. A recent systematic review
on the noninvasive diagnostic tools for PCS concluded that, although CT is accessible and
fast technique, there are no studies available on its diagnostic value for PCS. Moreover, its
ionizing properties are a disadvantage in terms of studying a population of mostly young
women of fertile age. Regarding the MRI presents a high sensitivity raging between 88
and 100% while also allowing for the differential diagnosis with some other diseases such
as endometriosis. However, the lack of standardized criteria regarding PCS, along with
the small sample size in noncontrolled studies, and the limited availability in most clinics,
makes it difficult for its recommendation [8].
In comparison with other techniques, transvaginal ultrasound (TVU) is an easily
accessible, nonionizing, and minimally invasive technique. It allows for the measurement
of pelvic veins and blood flow identification in real time [13]. The main disadvantage is
that it requires the examiner to possess some experience, alongside the difficulty involved
in properly identifying the ovarian veins. Several parameters have been proposed for the
ultrasonographic diagnosis of PCS, such as the dilation of ovarian veins, low blood flow
velocity in the ovarian vein, or a dilated arcuate vein in the myometrium communicating to
pelvic varicosities [14]. Color Doppler imaging is essential to differentiate between cystic
images from varicose veins. It also allows for the identification of reverse or abruptly
interrupted flow during Valsalva, which is associated with the backflow or stasis of blood,
respectively, identified in ovarian venography [4].
However, there still is some controversy regarding the reference values for the diameter
of ovarian veins, with the pathological cut-off raging between 5 and 8 mm. In this study,
we aim to determine whether transvaginal 2D and Doppler ultrasonography are useful
and reliable diagnostic tools for PCS in comparison with venography, as well as to establish
ultrasound parameters for said purpose.

2. Materials and Methods

An observational and cross-sectional prospective study was carried out in the Gyneco-
logical Ultrasound Unit at the Valme University Hospital between November 2018 and July
2020. Patients were consecutively recruited, including all patients referred by the Pelvic
Floor, Gynecology and Vascular Surgery Units, that met the inclusion criteria. The study
was approved by Andalucia’s board of biomedicine ethics committee (Code 1314/2017).
All participants gave informed consent.

2.1. Subjects
The patients included in the study were distributed in two groups depending on
whether the subsequent venography results confirmed the presence of PCS. The inclusion
criteria were women presenting noncyclical pelvic pain for 6 months or longer. The
exclusion criteria were the patient’s refusal to undergo a venography.

2.2. Data Collection

For the collection of epidemiological data, the patients completed a questionnaire
form prior to the diagnostic tests. These parameters were: age; parity; maximum newborn
birth weight; menopausal stage; age of the onset of symptoms; worsening of symptoms
after pregnancy; presence of vulvar varicosities during pregnancy; prior medical history of
endometriosis, adenomyosis, urologic, or gastrointestinal disorders; presence of varicosities
Tomography 2022, 8 91

in lower extremities; prior pelvic surgery; presence of uterine fibroids; and the presence of
varicosities in the vulva, perineum, buttocks, or lower extremities. In addition, patients
stated the levels of pain they experienced in the following cases: walking, sitting, in the
supine position, dysmenorrhea, dyspareunia, postcoital pain, and lumbar pain. Level of
pain was considered clinically significant when the VAS score was 7 or higher.

2.3. Ultrasound Assessment

Ultrasonography assessment was performed by an expert examiner with more than
15 years of experience in gynecological ultrasonography, using a Canon Aplio 500 (Toshiba
Medical systems Corp., Tokyo, Japan) with a 6.5 MHz probe. Patients were placed in the
gynecological position right after urinating in order to perform the assessment with an
empty bladder, as is usual procedure for gynecological ultrasonography assessment.
The ultrasound evaluation began with the complete evaluation of the uterus in the
longitudinal and cross-sectional planes, followed by the assessment of the adnexa. Uterine
and ovarian volumes were calculated using the simplified formula for prolate ellipsoid [15].
Consecutively, we proceeded to identify the largest pelvic vein (after tracking the uterine
vein from its origin at the internal cervical os to the internal iliac veins and collateral
branches) along with the complete venous plexus, measuring their anteroposterior diameter
in a cross-sectional plane. Subsequently, color and spectral Doppler was used to identify
the flow direction and whether there was a change in the flow velocity waveform during
Valsalva. The same procedure was repeated for the contralateral side. Afterwards, in a
cross-sectional plane of the uterus, color Doppler was used to identify the presence of
crossing veins in the myometrium, measuring its maximum anteroposterior diameter.
Therefore, the parameters collected in the ultrasound assessment were uterine volume,
right and left ovarian volume, presence of polycystic ovaries (PCO), inner diameter of the
largest pelvic vein (right and left side), maximum diameter of the largest venous plexus
(right and left side), reverse or altered flow during Valsalva, presence of crossing veins
in the myometrium, and maximum diameter of crossing veins in the myometrium. The
ultrasonography diagnosis of PCS was based on the established cut-off point of 8 mm
diameter for the largest pelvic venous vessel.
After the ultrasound assessment, patients underwent a pelvic venography, performed
by specialists in angiology and vascular surgery. The diagnosis of PCS was based on the
presence of the dilation of ovarian veins ≥ 10 mm, congestion and/or valvular insuffi-
ciency [16,17]. If the diagnosis was confirmed, embolization was made during the same
procedure in all 39 patients who were diagnosed with PCS.

2.4. Statistical Analysis

Statistical analysis was performed with the statistics software IBM SPSS version 22
(IBM, Armonk, NY, USA). Numeric variables were described as mean and standard devia-
tions for normally distributed variables, while median and interquartile range were used
for non-normally distributed variables. Percentages were used for qualitative variables.
Normality of the data was made with the Shapiro–wilk test. Comparisons of numeric
variables was evaluated using Student’s t-test in case of normally distributed data, while
the Mann–Whitney U-test was used for non-normally distributed data. The Chi-square
test was used for comparisons of qualitative variables. Statistical significance was set at
p < 0.05.

3. Results
A total of 67 patients who met the inclusion criteria were invited to participate in the
study. Out of the 67 patients included, only 51 completed the study and were distributed
in two groups according to the venography results: 39 patients belonging to the PCS group
(PCSG) and 12 to the normal group (NG).
There were no statistically significant differences between study groups regarding
epidemiological data. The mean age of patients was 44.85 ± 9.92 and 41.5 ± 6.95 years in
Tomography 2022, 8 92

the PCSG and NG, respectively, with most women being multiparous (74.3% PCSG; 91.6%
NG). Only 11.8% of all patients were menopausal, as were 7.69% of the PCS patients. The
mean age of the on-set of symptoms were 37 years in the PCSG and 31 years in the NG.
Around 60% of PCS patients had vulvar varicosities during pregnancy, with worsening of
the symptoms after pregnancy in 70% of them, which differs from the NG, in which only
50% of patients experienced said worsening of symptoms. The rest of the epidemiological
variables showed similar results in both groups, with no statistically significant differences,
as can be seen in Table 1.

Table 1. Epidemiological data.

Variables PCS Group Normal Group All Patients p

Age 41.5 ± 6.95 44.85 ± 9.92 42.2 ± 7.8 0.212
Multiparity 29 (74.3%) 11 (91.6%) 40 (80%) 0.197
Maximum newborn birth weight 3565.56 ± 546.7 3665 ± 442.14 3591.9 ± 518.5 0.476
Menopausal 3 (7.69%) 3 (25%) 6 (11.8%) 0.165
Age of the on-set of symptoms 31.5 ± 8.5 37.25 ± 12.7 32.96 ± 9.9 0.847
Worsening of symptoms during pregnancy 27 (69.2%) 5 (41.6%) 32 (64%) 0.119
Vulvar varicosities during pregnancy 24 (61.5%) 8 (66.6%) 32 (64%) 0.83
Medical history 33 (84.6%) 10 (83.3%) 43 (84.3%) 0.396
Endometriosis 1 (2.5%) 1 (8.3%) 2 (3.9%) 0.449
Adenomyosis 1 (2.5%) 2 (16.6%) 3 (5.9%) 0.156
Urologic disorders 3 (7.69%) 0 (0%) 3 (5.9%) 0.405
Gastrointestinal disorders 0 (0%) 1 (8.3%) 1 (2%) 0.255
Varicosities in lower extremities 27 (69.2%) 6 (50%) 33 (64.7%) 0.105
Prior pelvic surgery 3 (7.9%) 2 (16.6%) 5 (9.8%) 0.378
Fibroids 4 (10.2%) 3 (25%) 7 (13.7%) 0.256
Presence of varicosities (vulva, perineum,
29 (74.3%) 7 (58.3%) 36 (70.6%) 0.14
buttocks, lower extremities)
Pain (VAS score ≥ 7)
Walking 21 (53.8%) 7 (58.3%) 28 (56%) 0.856
Sitting 19 (48.7%) 4 (33.3%) 23 (46%) 0.2
Supine 15 (28.4%) 5 (41.6%) 20 (40%) 0.895
Dysmenorrhea 23 (58.9%) 7 (58.3%) 30 (60%) 0.599
Dyspareunia 16 (41%) 4 (33.3%) 20 (40%) 0.43
Postcoital pain 22 (56.5%) 9 (75%) 31 (62%) 0.532
Lumbar pain 13 (33.3%) 4 (33.3%) 17 (34%) 0.775
PCS: Pelvic congestion syndrome; VAS: Visual Analogue Scale.

Regarding ultrasound variables, results are shown in Table 2. There were statisti-
cally significant differences in the presence of reverse or altered flow during Valsalva
(58.9% PCSG vs. 25% NG; p = 0.04) and crossing veins in the myometrium (74.35% PCSG
vs. 33.3% NG; p = 0.009). There were no differences between groups in the diameters of
right or left venous plexus, although, when comparing the diameters of the largest venous
plexus with both sides combined, we found that PCS patients had a larger venous plexus
diameter than normal patients (15.1 mm vs. 12 mm; p = 0.009). The presence of any pelvic
vein of ≥8 mm was also significatively higher in PCS patients (92.3% vs. 25%; p < 0.000).
None of the rest of ultrasound variables reached statistical significance.
Tomography 2022, 8 93

Table 2. Ultrasound Parameters.

Variables PCS Group Normal Group All Patients p

Uterine volume 80 ± 30.8 73 ± 66.8 79.7 ± 41.4 0.626
Right ovarian volume 9.94 ± 6.2 13.6 ± 13.1 10.65 ± 8 0.514
Left ovarian volume 12.64 ± 8.5 15.2 ± 14.4 13.26 ± 9.9 0.5
PCO 6 (15.8%) 3 (23.1%) 9 (17.6%) 0.552
Largest pelvic vein Ø 6.3 ± 4.5 4.8 ± 1.3 5.9 ± 2.8 0.308
Right side 6.8 ± 12.4 3.9 ± 1.7 5.9 ± 10.5 0.411
Left side 6.1 ± 3.2 4.7 ± 2.1 5.7 ± 2.9 0.187
Largest venous plexus Ø 15.1 ± 6.4 12 ± 5.2 16.9 ± 12.1 0.009
Right side 14.3 ± 7.9 10.5 ± 5.3 13.4 ± 7.4 0.185
Left side 18.4 ± 13.1 9.5 ± 4.3 15.9 ± 12.03 0.155
Reverse of altered flow during Valsalva 23 (58.9%) 3 (25%) 26 (51%) 0.04
Crossing veins in the myometrium 29 (74.35%) 4 (33.3%) 33 (64.7%) 0.009
Crossing veins in the myometrium Ø 3.5 ± 1.99 6 ± 4.2 3.75 ± 2.25 0.141
Pelvic vein Ø ≥ 8 mm 36 (92.3%) 3 (25%) 39 (76.5%) <0.000
PCS: Pelvic congestion syndrome; PCO: Polycystic ovaries; Ø: Diameter.

We also evaluated whether there were discrepancies in parameters based on laterality,

given the anatomical differences for venous return. We found that the largest pelvic vein on
the left side had a larger diameter than the one on the right side (6 mm vs. 4.5 mm; p = 0.011).
Ovarian volume and the venous plexus diameter did not reach statistical significance, as
can be seen in Table 3.

Table 3. Evaluation of differences based on laterality.

Variables Left Side Right Side p

Ovarian volume 8 ± 15.4 7.4 ± 7.99 0.646
Largest pelvic vein Ø 6 ± 3.6 4.5 ± 1.88 0.011
Largest venous plexus Ø 15.2 ± 8.75 15.5 ± 9.75 0.359
Ø: Diameter.

For the evaluation of the TVU diagnostic accuracy of PCS, in comparison with the
diagnostic gold standard pelvic venography (Table 4), we established the TVU diagnostic
criteria as the presence of any pelvic vein of 8 mm diameter or larger. In Table 5, we can
see that TVU, using this cut-off point, had a sensitivity and specificity of 92.31% and 75%,
respectively, with false positive and false negative rates of 7.69% and 25%. Positive and
negative predictive values were 92.28% and 75.07%, respectively, for a PCS prevalence
of 76.4%.

Table 4. Evaluation of the transvaginal ultrasound diagnostic accuracy of pelvic congestion syndrome
using the criteria of any pelvic vein diameter of 8 mm or larger.

Venography (Gold Standard)

Normal PCS Total p

Transvaginal Normal 9 3 12
Ultrasound PCS 3 36 39 <0.005
Total 12 39 51
PCS: Pelvic congestion syndrome.
Tomography 2022, 8 94

Table 5. Diagnostic values of transvaginal ultrasound for pelvic congestion syndrome using the
criteria of any pelvic vein diameter of 8 mm or larger.

Transvaginal Ultrasound Value CI 95%

Sensitivity 92.31% 78.03–97.99%
Specificity 75% 42.84–93.31%
Positive predictive value 92.28% 81.71–96.97%
Negative predictive value 75.07% 49.18–90.36%
False positive rate 7.69% 2.01–21.97%
False negative rate 25% 6.7–57.16%

In addition, a secondary analysis was performed to evaluate whether factors known

to increase pelvic veins diameters (parity, premenopause, adenomyosis, fibroids, and PCO)
were associated with larger pelvic veins or venous plexus diameters. No statistically
significant differences were observed in this regard (Table 6).

Table 6. Assessment of factors associated with larger diameters of pelvic veins.

Transvaginal Ultrasound Nulliparous Multiparous p

Largest pelvic vein Ø 5.6 ± 2.3 6.2 ± 2.9 0.25
Largest venous plexus Ø 16 ± 4.55 17.2 ± 12.6 0.75
Premenopause Menopause p
Largest pelvic vein Ø 6.2 ± 2.8 4.9 ± 2.1 0.43
Largest venous plexus Ø 16 ± 7.3 27.5 ± 35.2 0.33
No adenomyosis Adenomyosis p
Largest pelvic vein Ø 5.8 ± 2.8 6.9 ± 0.21 0.33
Largest venous plexus Ø 15.9 ± 11.6 - -
No fibroids Fibroids p
Largest pelvic vein Ø 6.1 ± 2.9 6.2 ± 0.61 0.7
Largest venous plexus Ø 17.1 ± 12.4 16.5 ± 5.7 0.17
Normal ovaries PCO p
Largest pelvic vein Ø 6.11 ± 2.9 6.2 ± 1.8 0.44
Largest venous plexus Ø 17.7 ± 12.8 14 ± 4.8 0.98
Ø: Diameter.

4. Discussion
It is difficult to know the real incidence of PCS given the lack of definitive diagnostic
criteria. It is estimated that the prevalence of PCS, although underdiagnosed, ranges
between 16 and 30% of CPP patients in whom other causes have been discarded [18]. In
our study, PCS prevalence was 76.4%. This discrepancy might be explained by the fact that
our patients were referred after a directed anamnesis and examination by a specialist in
angiology and vascular surgery, which might have caused some selection bias.
This disorder is usually diagnosed in multiparous women aged between 30 and
40 years, who suffer a worsening of symptoms after pregnancy, usually with the onset
of vulvar varicosities during said period. The explanation might lie in the increase of
up to 50% of the pelvic venous vessels’ capacity during pregnancy, which would lead
to venous insufficiency and backflow after pregnancy [2,4,18]. In our study, the mean
age of PCS patients was 41 years, while the on-set of symptoms was at 31 years. This
10-year delay could be based on the unawareness of this disorder by both patients and
medical professionals. Pelvic venous insufficiency is frequent in multiparous women
Tomography 2022, 8 95

due to major strains on the venous system during pregnancy. Despite this, we did not
find an association between PCS and multiparity, varicose veins during pregnancy, or a
worsening of symptoms after pregnancy, although the latter was 20% more frequent in the
PCS group [19].
Typically, PCS is considered a specific condition of premenopausal women, which
is explained by the decrease in estrogen and its vasodilator effect in menopause. This
explanation is backed by the improvement patients experience after pharmacological or
surgical induction of a hypoestrogenic state [20]. Nonetheless, the etiology and physiology
of PCS is multifactorial, thus we did not consider menopause as an exclusion criterion,
with 7.69% of PCS patients being in menopausal stage.
The most frequent symptoms of PCS are dysmenorrhea (84%), dyspareunia, and
postcoital pain (40.8%), which are usually accompanied by varicosities in the vulva (45.9%)
or in the lower extremities (58.7%) [18]. Our results are similar to this data, except our
dysmenorrhea rate in PCS patients was somewhat lower (58.9%).
It is also worth mentioning that, in our study, we found that pelvic veins on the left side
were significantly larger than on the right side, which is in agreement with the established
higher prevalence of PCS on the left side, given the existing anatomical differences between
both sides [21].
The main controverse in the diagnosis of PCS is the lack of consensus for what should
be considered as enlarged pelvic venous vessels. It is worth mentioning that the existence
of anatomical variations in the pelvic venous network may increase the difficulty of its
standardization and, moreover, the collapse of the varicose veins due to the filling of the
bladder when performing a transabdominal ultrasound assessment may increase difficulty
in this regard. The mean ovarian vein diameter is 3.8 mm when valves are competent and
7.5 mm if they are incompetent, therefore the cut-off point for dilated pelvic veins was set
at 5 mm. Thus, the dilation is considered mild if the diameter is between 5 and 7.9 mm or
severe if it is of 8 mm or larger. However, some authors have only used the cut-off point of
5 mm, and even apply the same criterion for any pelvic vein. Given these discrepancies, a
comparison of existing articles remains challenging [20,22]. Even more, whilst ovarian vein
imaging is feasibly achievable by venography or tomography, their small size and variable
location increase the difficulty of obtaining images by TVU.
Hence, the established criteria in our study for the ultrasonography diagnosis of PCS
was the presence of any dilated pelvic vein, with the cut-off point for dilation being 8 mm
(severe dilation), with the aim of establishing a reproducible technique.
To date, venography is still considered the gold standard for the diagnosis of PCS,
despite being an invasive technique that can only be performed in specialized centers,
which makes the introduction of new methods, such as ultrasonography, a necessity.
A meta-analysis including six studies that compared TVU with venography described
sensitivity and specificity rates ranging between 83 and 100% for the identification of pelvic
varicocele or ovarian vein ≥ 5 mm. However, it concluded that more studies are needed,
given the flawed methodology and heterogeneity of parameters [7,8,10,20,23].
Our main objective was to determine whether TVU is reliable for the diagnosis of
PCS and if it is comparable to venography, as well as to establish ultrasound parameters
for said purpose. Our results show that some ultrasound parameters are associated with
the PCS, such as a reverse or altered flow during Valsalva, the presence crossing veins in
the myometrium, and a larger maximum diameter of pelvic venous plexus. Even more,
the ultrasound criteria for the PCS established in this studio (any pelvic vein of ≥8 mm
diameter) showed good sensitivity (92.31%) and acceptable specificity (75%), with a low
false positive rate (7.69%). Even more, our study showed a high positive predictive value
(92.28%) when the PCS prevalence was of 76.4% or, in other words, with clinical suspicion
of PCS. Therefore, TVU is a valid alternative for venography that could be used in the first
assessment of patients suspected of having PCS. Images of these significant ultrasound
variables are displayed in Figures 1–4 and Videos S1 and S2. Comparative venography
images are shown in Figure 5.
Tomography 2022,8 8,
Tomography2022, 968
Tomography 2022, 8, 8
Tomography 2022, 8, 8

Figure 1. Crossingveins
veins inthe
the myometrium.
Figure1.1.Crossing
Figure Crossing veinsin
in themyometrium.
myometrium.
Figure 1. Crossing veins in the myometrium.

Figure 2. Largest pelvic vein diameter measurement.

Figure2.2.Largest
Figure Largestpelvic
pelvicvein
veindiameter
diametermeasurement.
measurement.
Figure 2. Largest pelvic vein diameter measurement.

Figure 3. Largest venous plexus diameter measurement.

Figure 3. Largest venous plexus diameter measurement.
Figure3.3.Largest
Figure Largestvenous
venousplexus
plexusdiameter
diametermeasurement.
measurement.
Tomography 2022,8 8,
Tomography2022, 979
Tomography 2022, 8, 9

Figure4.4.Reverse
Figure Reverseflow
flowduring
duringValsalva.
Valsalva.
Figure 4. Reverse flow during Valsalva.

Figure 5. Venography sequence: (A) Insufficient left ovarian vein with periuterine varices. (B) Com-
Figure 5. Venography
petent5.left ovarian veinsequence: (A) Insufficient
after embolization. left ovarian veinovarian
(C) Insufficient with periuterine varices. (B) Com-
Figure Venography sequence: (A) Insufficient left ovarianright vein withvarices.
vein with periuterine periuterine vari-
(B) Com-
petent
ces. left
(D) ovarian
Competent vein after
right embolization.
ovarian vein after(C) Insufficient
embolization. right ovarian vein with periuterine vari-
petent left ovarian vein after embolization. (C) Insufficient right ovarian vein with periuterine varices.
ces. (D) Competent right ovarian vein after embolization.
(D) Competent right ovarian vein after embolization.
Previous studies have described that the presence of PCO and other factors known
Previous studies have described that the presence of PCO and other factors known
to increase
Previousuterine
studiesvolume, such as parity,
have described premenopause,
that the presence of PCO adenomyosis, or fibroids,
and other factors known are
to increase uterine volume, such as parity, premenopause, adenomyosis, or fibroids, are
toassociated
increase uterine volume, such as parity, premenopause, adenomyosis, or fibroids,
with larger diameters of pelvic veins. Thus, patients with these characteristics are
associatedwith
associated withlarger
largerdiameters
diametersofofpelvic
pelvicveins.
veins. Thus,patients
patientswith
withthese
these characteristics
would require different cut-off points [20,22]. InThus,
our study, these patientscharacteristics
showed no in-
wouldrequire
would require different cut-off
cut-off points [20,22]. InInour study, these patients showed nonoin-
creased venousdifferent
diameters, hence points [20,22].cut-off
no different ourpoints
study,were
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made. showed
creased venous diameters, hence no different cut-off points were
increased venous diameters, hence no different cut-off points were made. made.
Tomography 2022, 8 98

Our study also has its limitations, one of them being the small sample size. It should
also be mentioned that the ultrasound evaluation was performed by only one expert
examiner in just a single act, and thus we were not able analyzed the intra- and inter-
observer reproducibility. We believe that our promising results should be confirmed in
future studies, where they would be carried out by nonexpert examiners, and where the
inter- and intra-observer reproducibility could be studied. It is also worth mentioning that
patients were not required to remain seated or in supine position for a period of time, nor
did they fast overnight before the ultrasound assessment, which might have hindered the
correct visualization of venous structures due to the interference of intestinal gas. These
limitations will be considered in future studies.

5. Conclusions
Transvaginal 2D and Doppler ultrasonography, with the described methodology, has
acceptable sensitivity and specificity values. Our findings suggest that transvaginal ultra-
sonography seems to be a promising tool for the diagnosis of pelvic congestion syndrome.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/tomography8010008/s1, Video S1: Crossing veins in the myometrium, Video S2: Reverse flow
during Valsalva.
Author Contributions: Conceptualization, J.A.S.-B. and J.V.G.-H.; methodology, A.F.-P.; formal
analysis, A.F.-P.; data curation, P.V., J.A.G.-M.; writing—original draft preparation, I.V., R.G.-J.,
J.A.S.-B.; writing—review and editing, I.V., R.G.-J., J.A.S.-B.; J.A.G.-M., A.F.-P., J.V.G.-H., P.V., I.P.-D.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by Ethics Committee of VALME UNIVERSITARY HOSPITAL
(protocol code 1314/2017) and date of approval (5-10-2017).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Conflicts of Interest: The authors declare no conflict of interest.

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