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Difficult-to-diagnose pelvic pain.

CASE The patient is a 34-year-old woman who has been seeing you about chronic pelvic pain for some time now. You have performed a thorough workup. You have ruled out fibroids, endometriosis, and inflammation, but you cannot seem to find a source for the patient’s pain. There is no evidence of bowel disease, such as Crohn’s disease, or of appendicitis. Findings from previous pelvic examinations and Pap smears have been normal, except for mild ovarian tenderness. The patient is not pregnant but has two living children. Pelvic sonograms have been unremarkable. You decide to order CT of the abdomen and pelvis with oral and IV contrast enhancement. CT can show abnormalities of the bowel; some vascular abnormalities; free fluid or air; abnormalities of the liver, spleen, or kidneys; and, in some cases, adnexal masses. This patient’s CT study is shown in Figure 1. What does it reveal? DISCUSSION The CT shows several enhancing serpentine structures (arrow) in the pelvic cavity on each side of the uterus. These structures represent varicose veins in the pelvic cavity. These can contribute to a condition known as pelvic congestion syndrome (PCS). PCS is an often overlooked diagnosis in the evaluation of women with chronic pelvic pain. Sometimes such women receive a wrong diagnosis of depression. Although the etiology of PCS is unknown, anatomic or hormonal abnormalities are thought to play a role. PCS should be considered if pelvic pain persists after other causes, including infection, bowel disease, endometriosis, and fibroids, are eliminated. Typically, a patient with PCS will be of childbearing age and multiparous. Symptoms include low backache, tenderness of the ovaries, frequent urination, postcoital pain, abnormal menses, and vaginal discharge. The patient may report that her symptoms worsen before or during menses, when standing, during or after intercourse, or during pregnancy. PCS can also be associated with a retroverted uterus, polycystic ovaries, and full