Pelvic congestion syndrome (PCS) is defined as chronic pelvic pain for more than six months, resulting from a chronic venous disorder associated with varicose dilatation and venous insufficiency of the pelvic venous plexuses and represents about 16-31% of the causes of chronic pervasive pain (Corrêa et al., 2019). The pathogenesis of pelvic venous congestion is not fully understood. It is multifactorial, involving congenital valvular anomalies, previous surgical interventions, and alterations in pelvic floor musculature (Ignacio et al., 2008). Additionally, pelvic venous reflux may result from central venous compression syndromes, such as Nutcracker Syndrome (compression of the left renal vein between the aorta and the superior mesenteric artery) or May-Thurner Syndrome (compression of the left common iliac vein by the right common iliac artery) (Knuttinen et al., 2023; Koo & Fan, 2014). These anatomical and functional abnormalities contribute to developing venous congestion and its associated symptoms.

The symptomatology of PCS typically includes a deep, dull ache accompanied by a feeling of heaviness in the lower abdomen, scrotum, or perineum. This discomfort may radiate to the thighs or buttocks and is frequently associated with varicosities in the lower extremities. Symptoms are often exacerbated during sexual activity, prolonged standing, or following physical exertion. (Knuttinen et al., 2023; Rezaei-Kalantari et al., 2023)

Diagnosis relies on a combination of clinical history, physical examination, and imaging studies. Pelvic Doppler ultrasound is often the first-line imaging modality, enabling real-time dynamic assessment of blood flow and identification of venous reflux or varicosities, however, due to their location, it is often insufficient to diagnose varicosities of pelvic venous plexuses in men, as opposed to women where transvaginal duplex ultrasonography (TVUS) allows a direct view into the pelvis (Dabbs et al., 2018). Magnetic resonance imaging (MRI) provides detailed anatomical visualization, particularly in complex cases, and is invaluable for assessing pelvic venous anatomy and identifying secondary causes of venous compression (Ignacio et al., 2008; Rezaei-Kalantari et al., 2023). However, transcatheter venography remains the gold standard, offering precise evaluation of pelvic vein reflux and dilation, as well as comprehensive mapping of the venous district. This technique is particularly valuable when non-invasive imaging yields inconclusive results or when planning interventional treatments (Brown et al., 2018).