Pelvic Congestion Syndrome: Treatments

Number: 0441

Policy

Aetna considers embolization (e.g., using metallic coils or foam/gel sclerotherapy) of ovarian veins, with or without the internal iliac veins, medically necessary for the treatment of pelvic congestion syndrome (PCS) when both of the following criteria are met:

  • The member has had a definitive diagnostic venography, computed tomography (CT) or magnetic resonance imaging (MRI); and
  • The member has failed a trial of appropriate pharmacotherapy (e.g., analgesics, hormonal therapy).

Aetna considers ovarian vein embolization for the treatment of PCS experimental and investigational when criteria are not met.

Aetna considers sacral nerve root neuromodulation experimental and investigational for the treatment of chronic pelvic pain because the effectiveness of this approach has not been established.

See also CPB 0050 - Varicose Veins, and CPB 0754 - Uterine Nerve Ablation (UNA) and Presacral Neurectomy (PSN).

Background

Pelvic congestion syndrome (PCS), also called pelvic venous incompetence (PVI), may be one of many causes of chronic pelvic pain (CPP). CPP is described as continuous or intermittent noncyclic pain, localized to the pelvic region, which lasts for six or more months.  

PCS may occur when valves within the pelvic veins weaken and cause blood to flow backward and pool, similar to varicose veins in the legs. Blood pooling in pelvic or ovarian veins may result in engorgement or thrombosis, causing pain and discomfort. Risk factors associated with PCS include congestion of veins in the lower extremities, hormonal imbalance, multiple pregnancies and polycystic ovarian disease. Symptoms of pelvic congestion syndrome include the following:

  • Continuous or recurring pain for at least six months
  • Initial sensation of fullness or heaviness, which can increase to severe pain, including during or after menstruation or intercourse
  • Pelvic pain that worsens toward the end of the day or after long periods of time standing
  • Persistent lower back pain
  • Vaginal discharge.

Pelvic congestion syndrome is manifested by pelvic pain of variable intensity, that is heightened before or during menses and that is aggravated by prolonged standing, fatigue and intercourse.  Laparoscopic and venographic evidence of varicosities confirm the diagnosis of PCS.  The traditional therapy for PCS includes both medical approaches (e.g., dihydroergotamine, ovarian suppression, and rheologic agents) and surgical approaches (e.g., hysterectomy, uterine ventro-suspension, ovarian vein ligation, and excision).

Ovarian vein embolization is a minimally invasive treatment alternative for PCS.  The technique, usually performed by an interventional radiologist, involves threading a catheter, guided by fluoroscopic X-ray imaging, through the groin to the ovarian veins.  If the imaging reveals a cluster of serpentine veins, tiny stainless steel coils and/or absorbable sponges, or liquids such as glue are passed through the catheter into the ovarian vein, forming a clot that subsequently blocks the accumulation of blood in the varices.  Careful selection of patients and use of appropriate angiographic and technical skills by the interventional radiologist are requisite for the success of this therapeutic alternative.

Chung and Huh (2003) assessed the effectiveness of various treatments for PCS in patients with different stress levels.  These investigators analyzed 106 patients with PCS confirmed with laparoscopy and venography, who did not respond to medication after 4 to 6 months medication.  They were divided into 3 groups:
  1. embolotherapy;
  2. hysterectomy with bilateral oophorectomy and hormone replacement therapy; and
  3. hysterectomy with unilateral oophorectomy. 
The visual analog scale was used to measure degree of pain; stress level data were scored with the revised social readjustment rating scale.  Embolotherapy was significantly more effective at reducing pelvic pain, compared to the other methods (p < 0.05).  The mean percentage decrease in pain was significantly greater in the patients with lower stress scores (p < 0.05).  The authors concluded that ovarian and/or internal iliac vein embolization appears to be a safe, well-tolerated, effective treatment for PCS that has not responded to medication.

Smith (2012) stated that PCS is one of many causes of chronic pelvic pain.  It is generally accepted that this is attributable to ovarian and pelvic vein incompetence that may result in varices in the lower limb leading to presentation in varicose vein clinics.  However, far more patients have pelvic varices associated with varicose veins in the lower limb than have PCS.  Magnetic resonance imaging and computed tomographic venography are usually used in the diagnosis of this condition and criteria have been established to identify pelvic varices.  Many different treatments have been used to manage the symptoms of pelvic congestion.  Hysterectomy combined with oophrectomy, open surgical ligation of ovarian veins and laparoscopic vein ligation have been used in the past.  The most common treatments used currently involve embolization of pelvic and ovarian veins.  The results of this treatment have been published in a limited number of clinical series, usually with fairly short follow-up periods.  These treatments may be complicated by migration of embolization of coils used to occlude veins.  The longest duration of follow-up currently reported is 5 years.  Limited clinical evidence supports the use of embolotherapy in the management of PCS.

Jeanneret and colleagues (2017) stated that knowledge of the anatomy of the pelvic, gonadal and renal veins is important to understand PCS and left renal vein compression syndrome (LRCS), which is also known as the nutcracker syndrome.  These investigators noted that LRCS is related to PCS and to the presence of vulvar, vaginal and pudendal varicose veins.  The diagnosis of the 2 syndromes is difficult, and usually achieved with computed tomography (CT) or phlebography.  The gold standard is the intravenous pressure measurement using conventional phlebography.  The definition of PCS is described as pelvic pain, aggravated in the standing position and lasting for more than 6 months.  Pain in the left flank and micro-hematuria is observed in patients with LRCS.  Women with multiple pregnancies are at increased risk of developing varicose vein recurrences with pelvic drainage and ovarian vein reflux after crossectomy and stripping of the great saphenous vein.  The therapeutic options are:
  1. conservative treatment (medroxyprogesterone),
  2. interventional (coiling of the ovarian vein), and
  3. operative treatment (clipping of the ovarian vein).  

Mahmoud and associates (2016) described the technique of transcatheter embolization, the complications thereof and the clinical results of the treatment for PCS.  These researchers performed a literature search using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November 2014.  A total of 20 studies (1,081 patients) were included in the review.  There were no randomized trials, and only 1 study included a control group.  The immediate technical success rate in the occlusion of the affected veins was 99 %; 17 studies reported the 1- to 3-month clinical success of 641 patients.  Of these, 88.1 % reported moderate-to-significant relief in the symptoms, and 11.9 % reported little or no relief.  In 17 studies, long-term results were reported, and the follow-up varied between 7.3 months and 5 years.  In late follow-up, 86.6 % reported relief of the symptoms and 13.6 % experienced little or no relief.  The authors concluded that the immediate success rate for the endovascular treatment of PCS was good and the complication rate low.  Most patients reported relief in the symptoms for up to 5 years after the procedure.  However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at C.

Trans-Venous Occlusion of Pelvic Vein Incompetence

Hansrani et al (2015) stated that chronic pelvic pain (CPP) affects 24 % of women worldwide; the cause cannot be identified in 40 % despite invasive investigations.  Dilated, refluxing pelvic veins may be a cause of CPP and treatment by trans-venous occlusion is increasingly performed when gynecological causes are excluded, but is it effective?  These investigators performed a systematic review of the literature published between 1966 and July 2014.  Two authors independently reviewed potential studies according to a set of eligibility criteria, with a third assessor available as an arbiter.  A total of 13 studies including 866 women undergoing trans-venous occlusion of pelvic veins for CPP were identified (Level of evidence: 1 study grade 2b, 12 studies grade 4).  Statistical significant improvements in pelvic pain were reported in 9 of the 13 studies.  Technical success was reported in 865 of 866 (99.8 %) with low complication rates: coil migration in 14 women (1.6 %), abdominal pain in 10 women (1.2 %) and vein perforation in 5 (0.6 %).  In a study on varicose veins of the legs, recurrence was seen in 13 % of 179 women 5-years following coil embolization.  Subjective improvements in pain were seen in all 13 studies after treatment by trans-venous occlusion.  All 13 studies were of poor methodological quality.  Complication rates were low and no fatalities occurred.   The authors concluded that well-designed studies are needed to examine if pelvic vein incompetence (PVI) is associated with CPP, and to explore whether trans-venous occlusion of PVI improves quality of life for these women.

An UpToDate review on "Vulvovaginal varicosities and pelvic congestion syndrome" (Johnson, 2015) states that, in patients with PCS and vulvar varices, the authors suggest treatment of ovarian vein reflux first. This generally leads to reduction in the size of vulvar varicosities. Local sclerotherapy can be performed subsequently, if needed.

Sacral Nerve Root Neuromodulation

An UpToDate review on "Treatment of chronic pelvic pain in women" (Barbieri, 2017) states, regarding sacral nerve root neuromodulation, that "In general, neuromodulation for CPP has not been well-studied.  Sacral nerve root neuromodulation for bladder related symptoms and pain is the best studied technique, but all trials are observational.  A review of published case series suggests a 40 to 60 % rate of improvement in pelvic pain symptoms after placement of either unilateral or bilateral lead placement [citing Mayer and Howard, 2008).  Follow-up has been up to 3 years in some series.  There is some information on laparoscopic intra-abdominal placement of a neuroprosthesis for CPP, but this work is still early in development and has not been widely used".

Embolization of Insufficient Pelvic Veins for Pelvic Congestion Syndrome

Drazic and colleagues (2019) stated that PVI may cause PCS that is characterized by chronic pelvic pain exacerbated by prolonged standing, sexual activity or menstrual cycle.  It may be treated by embolizing the dysfunctional pelvic venous drainage and sometimes resecting vulvar, perineal and thigh varices.  These researchers evaluated the results of embolization of insufficient pelvic or ovarian veins on PCS.  Analysis of 17 women aged 32 to 53 years, who underwent a selective coil embolization of insufficient pelvic and/or ovarian veins via the jugular, basilic or cephalic veins.  In the pre-operative period, all patients had a lower extremity venous duplex pelvic ultrasound (US) examination and some had an abdominal and pelvic CT angiogram.  The technical success of the procedure was 100 % and no complications were registered.  During a 32-month follow-up, no patient had symptoms of PVI or relapse of vulvar or thigh varices.  The authors concluded that embolization of insufficient pelvic and ovarian veins was a safe and successful procedure for the treatment of PVI or vulvar varices.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family
36246     initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family
36247     initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
+ 36248     additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)
37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation
75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis

CPT codes not covered for indications listed in the CPB:

64561 Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed
64581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)

HCPCS codes not covered for indications listed in the CPB:

A4290 Sacral nerve stimulation test lead, each

Other HCPCS codes related to the CPB:

J1110 Injection, dihydroergotamine mesylate, per 1 mg
J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg
J9202 Goserelin acetate implant, per 3.6 mg
J9217 Leuprolide acetate (for depot suspension), 7.5 mg
J9219 Leuprolide acetate implant, 65 mg
S0132 Injection, ganirelix acetate, 250 mcg

ICD-10 codes covered if selection criteria are met:

N94.89 Other specified conditions associated with female genital organs and menstrual cycle [pelvic congestion syndrome]

Trans-Venous Occlusion:

CPT codes covered if selection criteria are met:

37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) [metallic coils or foam/gel sclerotherapy]

ICD-10 codes covered if selection criteria are met:

N94.89 Other specified conditions associated with female genital organs and menstrual cycle [pelvic congestion syndrome]

The above policy is based on the following references:

  1. Asciutto G, Asciutto KC, Mumme A, Geier B. Pelvic venous incompetence: Reflux patterns and treatment results. Eur J Vasc Endovasc Surg. 2009;38(3):381-386.
  2. Bachar GN, Belenky A, Greif F, Atar E, Gat Y, Itkin M, Verstanding A. Initial experience with ovarian vein embolization for the treatment of chronic pelvic pain syndrome. Isr Med Assoc J. 2003;5(12):843-846.
  3. Ball E, Khan KS, Meads C. Does pelvic venous congestion syndrome exist and can it be treated? Acta Obstet Gynecol Scand. 2012;91(5):525-528.
  4. Barbieri RL. Treatment of chonic pelvic pain in women. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2017.
  5. Belenky A, Bartal G, Atar E, et al. Ovarian varices in healthy female kidney donors: Incidence, morbidity, and clinical outcome. AJR Am J Roentgenol. 2002;179(3):625-627.
  6. Capasso P, Simons C, Trotteur G, et al. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Interven Radiol. 1997;20(2):107-111.
  7. Champaneria R, Shah L, Moss J, et al. The relationship between pelvic vein incompetence and chronic pelvic pain in women: Systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess. 2016;20(5):1-108.
  8. Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med. 2003;201(3):131-138.
  9. Cordts PR, Eclavea A, Buckley PJ, et al. Pelvic congestion syndrome: Early clinical results after transcatheter ovarian vein embolization. J Vasc Surg. 1998;28(5):862-868.
  10. Correa MP, Bianchini L, Saleh JN, et al. Pelvic congestion syndrome and embolization of pelvic varicose veins. J Vasc Bras. 2019;18:e20190061.
  11. Creton D, Hennequin L, Kohler F, Allaert FA. Embolisation of symptomatic pelvic veins in women presenting with non-saphenous varicose veins of pelvic origin - three-year follow-up. Eur J Vasc Endovasc Surg. 2007;34(1):112-117.
  12. Daniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: A systematic review. J Vasc Interv Radiol. 2016;27(10):1478-1486.
  13. d'Archambeau O, Maes M, De Schepper AM. The pelvic congestion syndrome: Role of the 'nutcracker phenomenon' and results of endovascular treatment. JBR-BTR. 2004;87(1):1-8.
  14. Drazic B O, Zarate B C, Valdes E F, et al. Embolization of insufficient pelvic veins for pelvic congestion syndrome. Analysis of 17 cases. Rev Med Chil. 2019;147(1):41-46. 
  15. Edwards RD, Robertson IR, MacLean AB, Hemingway AP. Case report: Pelvic pain syndrome - successful treatment of a case by ovarian vein embolization. Clin Radiol. 1993;47(6):429-431.
  16. Gavrilov SG, Turischeva OO. Conservative treatment of pelvic congestion syndrome: Indications and opportunities. Curr Med Res Opin. 2017;33(6):1099-1103.
  17. Guirola JA, Sanchez-Ballestin M, Sierre S, et al. A randomized trial of endovascular embolization treatment in pelvic congestion syndrome: Fibered platinum coils versus vascular plugs with 1-year clinical outcomes. J Vasc Interv Radiol. 2018;29(1):45-53.
  18. Hansrani V, Abbas A, Bhandari S, et al. Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2015;185:156-163.
  19. Hobbs JT. Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract. 2005;59(10):1195-1203.
  20. Hocquelet A, Le Bras Y, Balian E, et al. Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome. Diagn Interv Imaging. 2014;95(3):301-306.
  21. Jeanneret C, Beier K, von Weymarn A, Traber J. Pelvic congestion syndrome and left renal compression syndrome - clinical features and therapeutic approaches. Vasa. 2016;45(4):275-282.
  22. Johnson NR. Vulvovaginal varicosities and pelvic congestion syndrome. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed March 2015.
  23. Katz MD, Sugay SB, Walker DK, et al. Beyond hemostasis: Spectrum of gynecologic and obstetric indications for transcatheter embolization. Radiographics. 2012;32(6):1713-1731.
  24. Kim HS, Malhotra AD, Rowe PC, et al. Embolotherapy for pelvic congestion syndrome: Long-term results. J Vasc Interv Radiol. 2006;17(2 Pt 1):289-297.
  25. Kwon SH, Oh JH, Ko KR, et al. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 2007;30(4):655-661.
  26. Laborda A, Medrano J, de Blas I, et al. Endovascular treatment of pelvic congestion syndrome: Visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 2013;36(4):1006-1014.
  27. Liddle AD, Davies AH. Pelvic congestion syndrome: Chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 2007;22(3):100-104.
  28. Lima MF, Lima IA, Heinrich-Oliveira V. Endovascular treatment of pelvic venous congestion syndrome in a patient with duplication of the inferior vena cava and unusual pelvic venous anatomy: Literature review. J Vasc Bras. 2019;19:e20190017.
  29. Lopez AJ. Female pelvic vein embolization: Indications, techniques, and outcomes. Cardiovasc Intervent Radiol. 2015;38(4):806-820.
  30. Mahmoud O, Vikatmaa P, Aho P, et al. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 2016;4(3):355-370.
  31. Marcelin C, Izaaryene J, Castelli M, et al. Embolization of ovarian vein for pelvic congestion syndrome with ethylene vinyl alcohol copolymer (Onyx®). Diagn Interv Imaging. 2017;98(12):843-848.
  32. Mayer RD, Howard FM. Sacral nerve stimulation: Neuromodulation for voiding dysfunction and pain. Neurotherapeutics. 2008;5(1):107-113.
  33. Nasser F, Cavalcante RN, Affonso BB, et al. Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome. Int J Gynaecol Obstet. 2014;125(1):65-68.
  34. Pieri S, Agresti P, Morucci M, de' Medici L. Percutaneous treatment of pelvic congestion syndrome. Radiol Med (Torino). 2003;105(1-2):76-82.
  35. Pyra K, Wozniak S, Roman T, et al. Evaluation of effectiveness of endovascular embolisation for the treatment of pelvic congestion syndrome -- preliminary study. Ginekol Pol. 2015;86(5):346-351.
  36. Ryder R. Chronic pelvic pain. Am Fam Physician. 1996;54(7):2225-2232, 2237.
  37. Smith PC. The outcome of treatment for pelvic congestion syndrome. Phlebology. 2012;27 Suppl 1:74-77.
  38. Tarazov PG, Prozorovskij KV, Ryzhkov VK. Pelvic pain syndrome caused by ovarian varices. Treatment by transcatheter embolization. Acta Radiol. 1997;38(6):1023-1025.
  39. Tu FF, Hahn D, Steege JF. Pelvic congestion syndrome-associated pelvic pain: A systematic review of diagnosis and management. Obstet Gynecol Surv. 2010;65(5):332-340.
  40. Venbrux A, Lambert DL. Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence. Curr Opin Obstet Gynecol. 1999;11:395-399.
  41. Venbrux AC, Chang AH, Kim HS, et al. Pelvic congestion syndrome (pelvic venous incompetence): Impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 2002;13(2 Pt 1):171-178.
  42. Whiteley MS, Lewis-Shiell C, Bishop SI, et al. Pelvic vein embolisation of gonadal and internal iliac veins can be performed safely and with good technical results in an ambulatory vein clinic, under local anaesthetic alone - Results from two years' experience. Phlebology. 2018;33(8):575-579.