pelvic congestion syndrome
Introduction
Introduction to pelvic congestion syndrome Pelvic congestion syndrome is a unique disease caused by chronic pelvic venous blood outflow, pelvic vein filling and congestion. Its clinical characteristics are "three pains and more than one less", that is, pelvic pain, low back pain, sexual pain, menstruation, vaginal discharge, and fewer gynecological examinations. Clinically, the severity of the disease was positively correlated with the nature of the pain. Open surgery showed thickening, detour, varicose or agglomeration of the pelvic vein. basic knowledge The proportion of illness: 0.03% Susceptible people: women. Mode of infection: non-infectious Complications: hematuria
Cause
Causes of pelvic congestion syndrome
Causes
Any factor that causes the pelvic venous outflow pelvic cavity to be poor or blocked can cause pelvic venous stasis. Compared with men, gynecologic pelvic circulation is very different in anatomy, circulation dynamics and mechanics, and is easy to form. The basis of pelvic blood stasis.
First, anatomical factors
The characteristics of female pelvic circulation are mainly the increase in the number of veins and the weak structure.
The pelvic medium veins, such as uterine veins, vaginal veins and ovarian veins, are usually 2 to 3 veins accompanied by an artery of the same name. The ovarian veins can even be as many as 5 to 6, forming a vine venous plexus, bent at the sides of the uterus. Until they flow through the pelvic margin, a single ovarian vein is formed. There are many anastomotic branches in the uterus, fallopian tube, and ovarian vein. In the oviductal mesenteric, there is an anastomosis between the uterine vein and the ovarian vein, and a ring-shaped vein is formed. Circulation, and then with the external ovarian venous plexus, originated from the pelvic organ mucosa, muscle layer and subserosal venous plexus, pooled into more than two veins, flow to the large internal iliac vein, the number of pelvic veins increased In order to adapt to the slow flow of pelvic veins.
The pelvic vein is thinner than the vein wall in other parts of the body, lacking the outer sheath composed of fascia, no valve, lack of elasticity, and walking through the pelvic loose connective tissue, thus easily expanding and forming numerous curved venous plexus, small and medium pelvic cavity The vein only has a valve before it enters the large vein, and some women often have valvular insufficiency. These characteristics make the venous system of the pelvic organ, like a swamp connected by a water network, capable of accommodating a large number of rapidly flowing arteries. blood.
In addition, the venous plexus of the three systems of the bladder, genital organs and rectum communicate with each other. Due to the lack of valves, any systemic circulatory disturbance between the three can affect the other two systems.
Based on these anatomical features of the pelvic vein, if it is affected by the following related factors, it will lead to pelvic congestion syndrome, and it will show various clinical signs.
Second, physical factors
In some patients, due to physical factors, the vascular wall tissue is significantly weak, the elastic fiber is small, the elasticity is poor, and it is easy to form venous blood flow stagnation and varicose veins. Even if the first pregnancy is not engaged in standing or sitting for a long time, it may appear. Lower limbs and / or pelvic varicose veins and pelvic congestion syndrome.
Third, the mechanical factors
Different mechanical factors have been shown to affect the flow rate of the pelvic blood, thereby changing the pressure of the local blood vessels, and the veins are more susceptible to it.
(1) Position: For a long time engaged in standing or sitting workers, the pelvic venous pressure continues to increase, and it is easy to cause pelvic congestion syndrome. These patients often complain that the long-term standing sedentary lower abdominal pain, increased back pain, vaginal discharge and menstrual flow Add more, and after rest, the symptoms are often relieved. In addition, those who are used to sleeping in the supine position, due to the gravity of the uterus and the filling of the uterus, can shift the uterus backwards, which can also affect the pelvic vein outflow. From a mechanical point of view Said that in the habitual supine sleep, most of the pelvic veins are located lower than the inferior vena cava, which is not conducive to the pelvic vein outflow pelvic cavity, lateral or prone position sleep is beneficial to the pelvic vein outflow.
(2) uterine posterior tilt: uterine posterior tilt in gynecological patients accounted for 15 to 20%, may be higher in the maternal, 100 years ago, people thought that the uterus is the cause of various pelvic symptoms, and At the beginning of this century, people gradually realized that most of the activities of the uterus are backward without any symptoms, no treatment, only a part of the uterus leaning back to the pain, but many doctors believe that there are a few Active uterine posterior tilt can cause pelvic pain.
[Pathogenesis]
Pelvic venous congestion is considered to be the main pathological change of the disease. The cause of the above-mentioned "three pains" caused by pelvic venous congestion may be caused by the expansion of the curved vein to compress the accompanying lymphatic vessels and nerve fibers. Due to the aforementioned various factors, Firstly, a part of the pelvic veins with weak anatomical structure changes in function, affecting the blood flow and forming stasis; and through the interaction between the nerve vessels, affecting the entire reproductive organs and the breasts closely related to the reproductive organs, the clinical appearance Symptoms of the syndrome, edema of local tissues and related organs caused by congestion, but at the beginning is temporary, reversible, persistent for many years or repeated, can produce persistent changes, connective tissue due to chronic hypoxia Hyperplasia and fibrosis formation, the uterus body is consistently hypertrophied, softened, congested, purple or with congestion spots and subserosal edema; the cervix is also hypertrophic blue-violet, with erosion; endometrial edema, blood vessels Filling, the ovary also shows edema-like, rough white membrane, generally larger and sometimes cystic; long-term congestion However, it is hardened and become smaller due to the proliferation of connective tissue, which often leads to premenstrual pelvic pain and discomfort and increased menstrual flow, and the breast causes pain due to periodic edema.
Prevention
Pelvic congestion syndrome prevention
Carry out the "prevention-oriented" policy and take preventive measures against the cause of pelvic septicemia to avoid or reduce its occurrence.
Strengthen family planning publicity, prevent early marriage, early childbirth, sexual intercourse and birth, and promote the birth of two children at most. The two production should be at least 3 to 5 years apart, so that the reproductive organs are not only in anatomical and physiological functions. Moreover, the performance of blood vessels has to be fully restored, publicized scientific methods of contraception, no sexual intercourse to interrupt contraception, and no abstinence.
Paying attention to physical exercise, enhancing physical fitness, and improving general health are especially important for some people with weak constitutions.
Strengthen post-natal health promotion and promote post-natal gymnastics, which is of great benefit to the recovery of reproductive organs and their supporting tissues. Avoiding habitual supine position during rest or sleep, and promoting alternate lateral lying on both sides, is conducive to preventing the formation of posterior uterus. To prevent postpartum constipation and urinary sputum, help restore the reproductive organs and reflux of the pelvic veins.
Pay attention to the combination of work and rest, avoid excessive fatigue. For long-term workers who are standing or sitting, it is necessary to carry out workplace exercises and appropriate activities. In addition, whether you can fall asleep or not, you can rest in bed for a period of time at noon, which can eliminate the morning. Fatigue, but it is worth mentioning that different postures have different effects on relieving fatigue and improving pelvic blood transport when resting or sleeping. From a mechanical point of view, most of the pelvic veins are in a low position in the supine position. In the inferior vena cava, although the venous pressure is reduced when standing or sitting, it is obviously increased when it is in the prone position. The predecessors in the body-building work have "station like a pine, sitting like a bell, lying like a bow" The inscription, therefore, advocates the habitual use of the blood-legged prone position, which has a good effect on preventing or even treating some mild pelvic septicemia.
Complication
Complications of pelvic congestion syndrome Complications
About one-third of patients have bladder irritation, which is characterized by obvious urinary frequency during menstruation, which is easy to be mistaken for urinary tract infection. Cystoscopy sees venous filling in the bladder triangle, congestion, edema, and venous venous in individual patients. It is ruptured with hematuria.
Symptom
Symptoms of pelvic congestion syndrome Common symptoms Low back pain, abdominal pain, lower abdominal pain, postpartum abdominal pain, bloody dysmenorrhea, breast pain, sexy unpleasant abdominal muscle tension, blood spot, blood accumulation
The main manifestations of pelvic congestion syndrome are a wide range of chronic pain, extreme fatigue and certain neurasthenia symptoms, including chronic lower abdominal pain, low back pain, unpleasant pleasure, extreme fatigue, excessive leucorrhea and Dysmenorrhea is the most common, almost 90% of patients have the above symptoms of varying degrees. The so-called chronic pain means that all forms of pain last for more than half a year, the frequency is not less than 5 days per week, and the pain time per day is not less than For 4 hours, in addition, patients often have menorrhagia, premenstrual breast pain, premenstrual bowel pain, bladder irritation and vaginal pain, anal pain, etc. These symptoms are aggravated in the afternoon, evening or after standing. After sexual intercourse, menstruation is even worse before coming.
Examine
Examination of pelvic congestion syndrome
1. Vaginal ultrasound color Doppler examination.
2. Laparoscopy: The same as open surgery, but because of the pelvic elevation, some cases may not be able to see the varicose veins, but can be identified with other lesions such as inflammation.
3. Spiral CT: Recently, it has been reported in the literature that spiral CT is a non-invasive effective method for diagnosing pelvic venous congestion syndrome. When the patient takes deep breathing, he takes a spiral CT image of the artery, which causes an increase in abdominal venous pressure during deep breathing, resulting in kidney. Venous blood retrograde, filling the varicose veins around the uterus and ovary, the diameter of the varicose veins can be developed >5mm, conventional CT only shows some dilated veins, and has nothing to do with pelvic venous congestion syndrome.
4. Pelvic venography: Pelvic venography is the injection of contrast medium into the musculocutaneous muscle layer, so that the uterine vein, ovarian vein and part of the vaginal vein, internal iliac vein, and filming at regular intervals, understand The time when pelvic blood (mainly uterine vein and ovarian vein) flows out of the pelvis is used as a method to assist in the diagnosis of pelvic congestion. When the pelvic venous blood is normal, the contrast agent usually flows out of the pelvis completely within 20s. In the case of pelvic congestion, The venous return rate is significantly slower, and the contrast agent flows out of the pelvis and takes more than 20 seconds.
5. Radionuclide pelvic blood pool scan: This method is used to diagnose pelvic venous congestion after tubal ligation. The principle is varicose veins in the pelvic venous congestion, blood stasis forms a "blood pool", thus obtaining radioactive read nuclide Poly scanned image.
6. Postural examination, when the chest and knee are lying, the pelvic vein pressure is reduced, no lower abdominal pain or slight pain. If you immediately change your hips and sit tightly on the heel, keep it slightly above the abdomen, due to groin flexion. Tight, the external iliac artery is blocked by blood flow to the femoral artery, so that the blood flow of the internal iliac artery increases, causing the pelvic venous pressure to rise and causing congestion. When the lower abdominal pain returns to the chest and knee, the symptoms are relieved, which is called "positive position test." ".
Diagnosis
Diagnosis and differentiation of pelvic congestion syndrome
diagnosis
Symptoms of pelvic septicemia involve a wide range of symptoms, and the signs are mixed with some other lesions, so often cause clinical diagnosis difficulties, but if you can ask for a detailed history, pay attention to the differences between symptoms and signs, except for other related diseases. Appropriate application of pelvic venography and laparoscopy can make a more reliable diagnosis. The following points can be used as reference:
First, the majority of patients are women of childbearing age, have had two or more births, a history of abortion, shortly after a certain production or abortion, the above-mentioned chronic pelvic pain, low back pain, sexy discomfort, dysmenorrhea and other symptoms, but No postpartum or post-abortion infection history.
Second, the symptoms are not compatible with the objective examination, the symptoms of the patient are more serious, and the gynecological examination only sees the cervical hypertrophy, purple blue, and some have erosion, the uterus falls into the concave bone, but such as a fierce touch If the cervix or the cervix is touched, it will cause quite serious pain in the pelvic cavity and lumbosacral region. There is obvious tenderness and fullness in the parametrial and accessory areas. If you continue to touch slowly, there is a soft sponge feeling. Chronic appendicitis often has thickened and hard cords, and there is no abdominal muscle tension and rebound tenderness. When attempting to make the uterus back into the anterior position by hand, the patient feels painful. .
Third, often accompanied by premenstrual breast swelling and some symptoms of neurasthenia.
Fourth, although it was diagnosed as "chronic attachment inflammation" or "chronic pelvic inflammatory disease", it rarely interfered with pregnancy, even after being diagnosed as chronic attachment inflammation after abortion, the symptoms were not cured and then became pregnant.
Fifth, the various treatments performed according to the chronic pelvic cavity have not been effective, or even no effect. The patient consciously has serious gynecological diseases, and he has been cured for a long time and is regarded as a refractory disease by gynecologists.
Sixth, for the above symptoms, after gynecological examination and other auxiliary diagnostic methods, such as hysterosalpingography, etc., to exclude pelvic organic lesions, and clinical suspected pelvic venous hemorrhage, feasible pelvic venography to assist diagnosis, after detailed implementation .
Pelvic venography pelvic venography is the injection of contrast medium into the muscle layer at the bottom of the uterine cavity, so that the uterine vein, ovarian vein and part of the vaginal vein, the internal iliac vein are developed, and the film is continuously taken at intervals of time to understand the pelvic cavity. The time when blood (mainly uterine veins and ovarian veins) flow out of the pelvis is used as a method to aid in the diagnosis of sepsis.
When the pelvic venous blood is normal, the contrast agent usually flows out of the pelvis completely within 20 seconds. In the case of pelvic hemorrhage, the venous return rate is significantly slower, and the contrast agent flows out of the pelvis, which takes more than 20 seconds.
General pathology: vulva veins and filling and even varicose veins, vaginal mucosa purple blue coloration, cervical hypertrophy, edema, cervical mucosa often showing valgus erosion, surrounding mucous membrane purple blue color, sometimes can be seen in the posterior lip of the cervix filling small Intravenous, cervical secretions, a lot of surgery, the vast majority of patients fall in the uterus, the surface is purple-blue bloody or yellow-brown blood spots and subserosal edema, can be seen filling, varicose The uterine vein, the ovarian venous plexus on both sides is like a pile of sacral curvature on the lateral side of the uterus, which may be heavier on the one side than on the other side, sometimes as abnormal as a venous tumor, and the vein in the fallopian tube is also more Normally thickened and filled, the diameter can reach 0.8-1.0cm, and some are venous tumor-like. After the uterus is moved into the anterior position, it is possible to see a peritoneal laceration in the posterior lobe of the broad ligaments on both sides, a few lacerations. Like the large eye cracks, the laceration can extend inward to the patellofemoral ligament like the lack of some, the laceration is small, and the posterior ventral tract is thin, visible filling, varicose uterine veins from the laceration Out, usually, no more than In 10 minutes, you can see that the uterus in the front position has been restored from purple blue to normal reddish color, under the microscope, endometrial interstitial edema, venous filling, dilatation, ovary is generally larger, cystic, showing edema Like, breast gland edema, congestion, leading to breast pain, in the case of wide ligament laceration and III degree uterus posterior tilt, uterine rectal depression may have a pale blue serous liquid ranging from 30 to 80 ml.
Should be differentiated from pelvic endometriosis, chronic attachment inflammation (formation of inflammation), uterine fibroids, cervical erosion.
