HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rozenblit, A. M. Articles by Amis, E. S. Search for Related Content PubMed PubMed Citation Articles by Rozenblit, A. M. Articles by Amis, E. S., Jr. Social Bookmarking                      What's this?

Incompetent and Dilated Ovarian Veins

A Common CT Finding in Asymptomatic Parous Women

¹ All authors: Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467.

Received March 30, 2000; accepted after revision June 12, 2000.

 
Address correspondence to A. M. Rozenblit.

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. Incompetent and dilated ovarian veins have been reported in association with pelvic congestion syndrome. We postulate that incompetent and dilated ovarian veins are often an incidental CT finding, with a low diagnostic value. To verify our hypothesis, we studied the frequency of incompetent and dilated ovarian veins seen on CT in asymptomatic women.

MATERIALS AND METHODS. We retrospectively analyzed helical CT scans and medical records of 34 consecutive female renal donors between 18 and 46 years old (mean age, 33 years). An incompetent and dilated ovarian vein was defined as a contrast-filled vein measuring 7 mm or greater, seen during the arterial phase of helical CT.

RESULTS. Incompetent and dilated ovarian veins were found in 16 (47%) of 34 asymptomatic women. All 16 women had left ovarian vein involvement; six (37.5%) had bilateral involvement. The mean diameters for the left and right (incompetent and dilated) ovarian veins were 9.1 mm and 8.8 mm, respectively (range, 7-12 mm). Of 16 women with incompetent and dilated ovarian veins, 15 (94%) were parous. Of 18 women with normal ovarian veins, nine (50%) were parous. Overall, incompetent and dilated ovarian veins were found in 15 (63%) of 24 parous women, and in one (10%) of 10 nonparous women (p < 0.05).

CONCLUSION. Incompetent and dilated ovarian veins are frequently seen on CT in asymptomatic parous women. As an isolated finding, it is unlikely to be associated with pelvic congestion syndrome.

Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
Incompetence of the ovarian veins is considered the most likely etiology of pelvic congestion syndrome, typically seen in multiparous women of childbearing age [1, 2]. Pelvic congestion syndrome is manifested by chronic pelvic pain, usually without identifiable organic cause on numerous diagnostic tests including laparoscopy [3, 4]. However, it is believed that venous reflux and dilatation may lead to the development of periovarian pelvic varicosities, which may in turn lead to pelvic pain [5, 6]. Typically, the diagnosis of pelvic congestion syndrome is confirmed by selective renal and ovarian venography. It can also be suggested by helical CT, which may show incompetent and dilated ovarian veins and prominent pelvic veins [7]. However, the validity of CT for the diagnosis of pelvic congestion syndrome is unknown because an incidental dilated ovarian vein can be observed on CT performed for other reasons. To define the frequency of incompetent and dilated ovarian veins in asymptomatic women, we conducted a retrospective review of CT angiograms obtained in potential renal donors.

Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
We retrospectively analyzed helical CT scans of the abdomen of 34 consecutive healthy female potential renal donors between 18 and 46 years old (mean age, 33 years). In all subjects, CT scans were obtained for evaluation of the renal vasculature before planned kidney donation. All CT scans were obtained with a CTI helical scanner (General Electric Medical Systems, Milwaukee, WI) with a slice thickness of 3-mm, a pitch of 2:1, and reconstruction intervals of 1.5 mm. One hundred thirty mL of IV iohexol 300 (Omnipaque 300; Sanofi Winthrop, NY) was administered with a power injector at a rate of 4 mL/sec, with an injection-to-scan delay of 20 sec. The images were acquired during a suspended deep inspiration.

Retrospective analysis of axial CT scans was performed independently by two radiologists who reviewed the scans for the presence of incompetence and dilatation of ovarian veins. An ovarian vein was considered incompetent if it was completely opacified with IV contrast material during the arterial phase of CT angiography. An ovarian vein was defined as dilated when it measured 7 mm or greater in its maximal diameter. Veins smaller than 5 mm and nonvisualized veins were categorized as "smaller than 5 mm." Medical records of all subjects were reviewed with attention paid to any abdominal pain or gynecologic complaints. By their obstetric history, the women were separated into parous and nonparous groups; the number of births was not recorded.

Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
According to the medical records, all subjects were asymptomatic. All underwent a thorough physical examination, pelvic examination, and a Pap smear combined with extensive laboratory testing. No abnormal findings were present in 30 of 34 women. In four women, a pelvic examination suggested uterine enlargement. This was confirmed on sonography, which showed a mildly leiomyomatous uterus but no other abnormal findings in all four women. Based on their physical examinations, medical histories, and laboratory data, all women in the study were considered good candidates for kidney donation. Thirty-three of 34 women underwent donor nephrectomy; one candidate was deemed unsuitable for donation because of her complex renal vascular anatomy (multiple bilateral renal arteries) revealed on CT.

There were 24 parous and 10 nonparous women. Incompetent and dilated ovarian veins were found in 16 (47%) of 34 women. All 16 women had left-sided incompetent and dilated ovarian veins (Fig. 1); six (37.5%) of these women had bilateral involvement (Fig. 2). Dilated ovarian veins ranged from 7 mm to 12 mm, with a mean diameter of 9.1 mm for the left ovarian vein and 8.8 mm for the right ovarian vein. None of the donor candidates had ovarian vein dilatation without evidence of reflux. Reflux into the left ovarian vein without dilatation was found in two donors whose left ovarian veins measured 5 mm and 6 mm. In these two donors, reflux of contrast material was noted only in the most cranial 2 to 3 cm of the left ovarian vein (Fig. 3A,3B,3C,3D). Ovarian veins were normal size in 18 (53%) women; two of these women had minimal reflux. A mean diameter in this group could not be calculated because in 14 of 18 women one or both ovarian veins could not be reliably identified (Fig. 4).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —37-year-old asymptomatic parous woman with incompetent and dilated left ovarian vein. Helical CT scan shows IV contrast medium in dilated left ovarian vein (arrow) during arterial phase of CT angiography indicative of venous incompetence.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —25-year-old asymptomatic parous woman with bilateral ovarian venous incompetence and dilatation. Helical CT scan obtained during arterial phase of CT angiography shows retrograde filling of both right (large arrow) and left (small arrow) ovarian veins, which are dilated.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —42-year-old woman with minimal reflux into nondilated ovarian vein. Helical CT obtained during arterial phase at cranial aspect of left ovarian vein shows contrast material in (A) left renal vein (open arrow) and in (B and C) most cranial portion of left ovarian vein (arrow). Six millimeters caudally to level of C (D), ovarian vein is less dense than on more cranial sections because of only minimal reflux. Ovarian vein is not dilated (6 mm) and is located (B-D) lateral to lumbar vein (arrowhead).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —42-year-old woman with minimal reflux into nondilated ovarian vein. Helical CT obtained during arterial phase at cranial aspect of left ovarian vein shows contrast material in (A) left renal vein (open arrow) and in (B and C) most cranial portion of left ovarian vein (arrow). Six millimeters caudally to level of C (D), ovarian vein is less dense than on more cranial sections because of only minimal reflux. Ovarian vein is not dilated (6 mm) and is located (B-D) lateral to lumbar vein (arrowhead).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —42-year-old woman with minimal reflux into nondilated ovarian vein. Helical CT obtained during arterial phase at cranial aspect of left ovarian vein shows contrast material in (A) left renal vein (open arrow) and in (B and C) most cranial portion of left ovarian vein (arrow). Six millimeters caudally to level of C (D), ovarian vein is less dense than on more cranial sections because of only minimal reflux. Ovarian vein is not dilated (6 mm) and is located (B-D) lateral to lumbar vein (arrowhead).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —42-year-old woman with minimal reflux into nondilated ovarian vein. Helical CT obtained during arterial phase at cranial aspect of left ovarian vein shows contrast material in (A) left renal vein (open arrow) and in (B and C) most cranial portion of left ovarian vein (arrow). Six millimeters caudally to level of C (D), ovarian vein is less dense than on more cranial sections because of only minimal reflux. Ovarian vein is not dilated (6 mm) and is located (B-D) lateral to lumbar vein (arrowhead).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —31-year-old asymptomatic nonparous woman with competent ovarian vein. Helical CT scan obtained during arterial phase of CT angiography shows no IV contrast medium in left ovarian vein (arrow) indicating that ovarian vein is competent. Right ovarian vein is not visualized. Normal unopacified ovarian vein cannot be reliably distinguished from other normal retroperitoneal structures during arterial phase.

Of 16 women with incompetent and dilated ovarian veins, 15 (94%) were parous women, whereas among 18 donors with nondilated veins, only nine (50%) women were parous. The mean age in the group with dilated ovarian veins was 35.6 years, which is similar to the mean age of 31.3 years in the group with normal ovarian veins. Of 24 parous women, incompetent and dilated ovarian veins were present in 15 (63%). This diagnosis was significantly more frequent (p < 0.05, ² test; p < 0.0079, Fisher's exact test) than that of nonparous women, in whom an incompetent and dilated ovarian vein was seen in one (10%) of 10 subjects. There was no disagreement between the two observers for either measurements or categorization of the ovarian veins.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Retrograde flow into an ovarian vein is considered a likely etiology for pelvic congestion syndrome [1, 2, 8]. Retrograde flow is typically associated with ovarian vein dilatation [9, 10]. The diagnosis of pelvic congestion syndrome is contemplated in young women who have no other cause for chronic pelvic pain. The pain is typically aggravated by an increase in intraabdominal pressure, such as during bending and lifting, or by walking and prolonged standing. Patients may complain of premenstrual, menstrual, postcoital, and perineal pain. Pelvic congestion syndrome is often associated with vulvar, perineal, and lower extremity varices. Other complaints include bladder urgency and dyspareunia [1, 3, 4]. The pathophysiology of pelvic congestion syndrome is not completely understood. Many investigators believe that incompetence of the ovarian veins leads to progressive varicosities in the broad ligament and pampiniform plexus, which are associated with pelvic pain [1, 3, 5, 6]. Pelvic congestion syndrome is diagnosed most frequently in multiparous women. Therefore, it is suggested that the dilatation of the ovarian veins during pregnancy that normally occurs to compensate for a 60-fold increase in blood flow [11] is a likely cause of subsequent venous incompetence [1, 12, 13]. However, more recently, pelvic congestion syndrome has been described as affecting nulliparous women [14].

Venous drainage of the ovaries occurs via the ovarian plexus, which communicates with the uterine plexus in the broad ligament. The ovarian vein arises from the ovarian plexus as single or, less commonly, multiple trunks that ascend along the psoas major muscle and typically join together before entering the inferior vena cava or the left renal vein on the right and left side, respectively [9]. Autopsy studies have shown that valves are absent in the cranial portion of the ovarian vein in 15% of women on the left side and in 6% of women on the right side. The valves are incompetent on either side in 35-43%, with a higher frequency in multiparous women [13]. On angiography, retrograde filling of the left ovarian vein was noted to occur up to 19% of women [15]. The left ovarian vein is typically affected probably because it joins the left renal vein at a right angle, which may facilitate the reflux [12]. The right ovarian vein may be affected if the junction with the inferior vena cava is anomalous [12].

The diagnosis of pelvic congestion syndrome may be suggested by gray-scale and Doppler sonography, which typically show dilated periuterine veins [16]. However, complete depiction of venous anatomy and blood flow requires retrograde renal and ovarian venography [12]. In patients with pelvic congestion syndrome, a venogram usually shows incompetent and dilated ovarian veins [12]. Other criteria for diagnosis of pelvic congestion syndrome may include congestion of the uterine or ovarian plexus, filling of veins across the midline, and vulvar or thigh varicosities [2, 9, 17]. It is possible that associated valvular incompetence of other pelvic venous systems, including the internal iliac and external iliac drainage, is crucial in pathophysiology of pelvic congestion syndrome.

Retrograde filling of ovarian veins, when it occurs, can be easily shown by helical CT performed during the arterial phase. At that time contrast material should be present only in the arterial system and renal veins, but not yet in the ovarian veins. Therefore, early opacification of the ovarian vein that occurs simultaneously with opacification of the renal veins indicates retrograde venous flow due to valvular incompetence. This CT observation associated with prominent pelvic veins has been diagnostic for pelvic congestion syndrome in a patient who has subsequently undergone successful surgery [7].

The normal range of ovarian venous size in nongravid females of reproductive age is uncertain from the available literature. Only one article [18] has reported a mean ovarian vein diameter of 3.2 mm in a small control group of eight young asymptomatic women, in contrast to 6.7 mm in patients with pelvic congestion syndrome. The authors of that study used antegrade transuterine ovarian venography that did not allow direct assessment of retrograde flow in the main ovarian vein. In autopsy material of 101 women with an average age of 77 years, a mean value of the ovarian vein circumference was 10.5 mm, which translates into a 3.3-mm diameter [15]. In another anatomic study [13] of 54 randomly selected women, a mean ovarian vein diameter in nulliparous women was 2.6 mm as opposed to 3.4 mm in the parous group. The veins were significantly wider when valves were incompetent, with a mean diameter of 6.5 mm on the left side [13]. Giacchetto et al. [12] used retrograde renal and ovarian venography in 33 patients with pelvic pain and negative findings on laparoscopy. They reported a mean diameter of 3.6 mm in the 18 competent ovarian veins and 10.7 mm in the incompetent veins associated with pelvic varicosities found in patients with pelvic congestion syndrome. In our series, healthy women with incompetent ovarian veins had a mean left ovarian vein diameter of 9.1 mm on CT (this translates into 10.9 mm on angiography when a 20% radiographic magnification is assumed). Some distention of the ovarian veins may occur during helical CT as a result of increased intraabdominal pressure caused by a deep suspended inspiration. Nevertheless, there is a considerable overlap of ovarian vein-size values between patients with pelvic congestion syndrome and asymptomatic women of comparable age. In the group of women with nondilated veins, a mean diameter could not be calculated because in most women, small ovarian veins without reflux could not be differentiated from other retroperitoneal structures of a similar size (2-4 mm) (Fig. 1). All dilated veins in our series showed evidence of retrograde flow. Minimal reflux into only the most cranial portion of two nondilated veins was seen. These veins were considered competent according to documented criteria; reflux into the most cranial portion of the ovarian vein may be caused by the lack of an ostial valve, with a competent valve located slightly caudally [12, 15].

We chose a 7-mm threshold for ovarian vein dilatation, a greater number than the commonly quoted 5-mm maximum normal ovarian vein diameter [9, 10], because we wanted to compare incompetent veins in asymptomatic women with veins of similar size reported in patients with pelvic congestion syndrome. By the combined radiographic data of two previous investigations [12, 18], a mean diameter of the ovarian vein in patients with pelvic congestion syndrome was 8.7 mm. When corrected for 20% magnification, 8.7 mm translates into 7 mm on CT. Eight women in our series had veins larger than 8 mm, corresponding to a 10-mm ovarian vein diameter by radiographic measurements. The latter number is often quoted as associated with the diagnosis of pelvic congestion syndrome in symptomatic patients and as a threshold for transcatheter embolization of an abnormal ovarian vein [4, 17].

In the group with incompetent and dilated ovarian veins in our series, 94% of women were parous. In one instance, ovarian venous incompetence and dilatation were unexpectedly seen in a young asymptomatic nulliparous woman. We speculate that this finding may be a result of congenital absence of the venous valves, with primary venous reflux and subsequent dilatation. The cause and frequency of this finding in nulliparous women and its possible prognostic value for the future development of pelvic congestion syndrome are unknown. No statistical conclusion could be drawn on the basis of this single case in a small group of 10 nulliparous women.

Our study shows that incompetent and dilated ovarian veins can be seen in 47% of asymptomatic women, reaching 63% in healthy parous women. Obviously, in these women incompetent and dilated ovarian veins did not cause clinical pelvic congestion syndrome. However, in the clinical setting of pelvic pain, this common CT finding of ovarian venous incompetence and dilatation may be erroneously considered as a sign of pelvic congestion syndrome. Unfortunately, it is unknown whether women in our series had associated pelvic varices. Except for the four patients with mild leiomyomata, our patients had no clinical indication for imaging of the pelvis. The lack of such diagnostic information and a relatively small study group are the limitations of our study. Future studies of the abdomen and pelvis may clarify the difference between symptomatic and asymptomatic women with incompetent and dilated ovarian veins. Our data indicate that incompetent and dilated ovarian veins are frequently seen on CT in asymptomatic parous women and, when an isolated finding, are unlikely to be associated with pelvic congestion syndrome.

References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Hobbs JT. The pelvic congestion syndrome. Br J Hosp Med 1990;43:200 -206[Medline]
2. Lechter A, Alvarez A. Pelvic varices and gonadal veins. Phlebologie 1986;85:225 -228
3. Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol 1988;95:153 -161[Medline]
4. Cordts PR, Eclavea A, Buckley PJ, et al. Pelvic congestion syndrome: early clinical results after transcatheter ovarian vein embolization. J Vasc Surg 1998;28:862 -868[Medline]
5. Chidekel N. Female pelvic veins demonstrated by selective renal phlebography with particular reference to pelvic varicosities. Acta Radiol Diag 1968;7:193 -211
6. Reginald PW, Beard RW, Kooner JS, et al. Intravenous dihydroergotamine to relieve pelvic congestion with pain in young women. Lancet 1987;2:351 -353[Medline]
7. Desimpelaere JH, Seynaeve PC, Hagers YM, et al. Pelvic congestion syndrome: demonstration and diagnosis by helical CT. Abdom Imaging 1999;24:100 -102[Medline]
8. Mathis BV, Miller JS, Lukens ML, Paluzzi MW. Pelvic congestion syndrome: new approach to an unusual problem. Am Surg 1995;61:1016 -1018[Medline]
9. Kennedy A, Hemingway A. Radiology of ovarian varices. Br J Hosp Med 1990;44:38 -43[Medline]
10. Venbrux AC. Ovarian vein and pelvic varices in the female. In: Savader SJ, Trerotola SO, eds. Venous interventional radiology with clinical perspectives. New York: Thieme, 1996: 159-162
11. Hodgkinson CP. Physiology of the ovarian veins during pregnancy. Obstet Gynecol 1953;1:26 -37[Free Full Text]
12. Giacchetto C, Catizone F, Cotroneo GB, et al. Radiologic anatomy of the genital venous system in female patients with varicocele. Surg Gynecol Obstet 1989;169:403 -407[Medline]
13. Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins: an anatomical and statistical study. Acta Radiol Diagn 1966;4:593 -601
14. Capasso P, Simons C, Trotteur G, et al. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol 1997;20:107 -111[Medline]
15. Ahlberg NE, Bartley O, Chidekel N. Retrograde contrast filling of the left gonadal vein. Acta Radiol 1965;3:385 -392
16. Giacchetto C, Cotroneo GB, Marincolo F, et al. Ovarian varicocele: ultrasonic and phlebographic evaluation. J Clin Ultrasound 1990;18:551 -555[Medline]
17. Sichlau MJ, Yao JST, Vogelzang RL. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol 1994;83:892 -896[Medline]
18. Beard RW, Highman JH, Pearce S, et al. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet 1984;2:946 -949[Medline]

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				Y. Asayama, K. Yoshimitsu, H. Aibe, A. Nishie, D. Kakihira, H. Irie, T. Tajima, K. Matake, T. Nakayama, Y. Ohishi, et al. MDCT of the Gonadal Veins in Females with Large Pelvic Masses: Value in Differentiating Ovarian Versus Uterine Origin Am. J. Roentgenol., February 1, 2006; 186(2): 440 - 448. [Abstract] [Full Text] [PDF]

				T. Hiromura, T. Nishioka, S. Nishioka, H. Ikeda, and K. Tomita Reflux in the Left Ovarian Vein: Analysis of MDCT Findings in Asymptomatic Women Am. J. Roentgenol., November 1, 2004; 183(5): 1411 - 1415. [Abstract] [Full Text] [PDF]

				S. J. Park, J. W. Lim, Y. T. Ko, D. H. Lee, Y. Yoon, J. H. Oh, H. K. Lee, and C. Y. Huh Diagnosis of Pelvic Congestion Syndrome Using Transabdominal and Transvaginal Sonography Am. J. Roentgenol., March 1, 2004; 182(3): 683 - 688. [Abstract] [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rozenblit, A. M. Articles by Amis, E. S. Search for Related Content PubMed PubMed Citation Articles by Rozenblit, A. M. Articles by Amis, E. S., Jr. Social Bookmarking                      What's this?