Venous Congestion Syndrome: Symptoms, Causes and Treatment Options

Venous congestion syndrome is a clinical condition in which deoxygenated blood cannot return to the heart due to dysfunction of the valves in the veins or a mechanical obstruction within the vessel, leading to blood pooling in the tissues and increased intravascular pressure. When it occurs particularly in the pelvic region, it is called Pelvic Congestion Syndrome. This vascular pathology is characterized by excessive dilation and varicosity of the veins in the lower abdomen. This stasis in the circulatory system is one of the main physiological causes of chronic pelvic pain, which reduces quality of life in women of reproductive age, worsens in the evenings, and is often overlooked in diagnosis.

What is venous congestion and why does it occur in our body?

To understand our circulatory system, we can liken it to the plumbing in our home. Clean water pipes, that is, the arteries, carry oxygen and nutrients to the tissues thanks to the heart’s powerful pump. However, when it comes to returning the used blood—through the veins—the situation becomes a bit more challenging. These “dirty water pipes” must carry blood upward against gravity, from the feet or abdominal cavity toward the heart.

To prevent blood from flowing backward during this uphill journey, our veins contain tiny valves. These act like one-way doors; they open as blood moves upward and snap shut when it tries to fall back down. Venous congestion begins when these doors fail. If the valves cannot close properly, the blood that should move upward succumbs to gravity and accumulates below.

Over time, this accumulation strains and enlarges the vessel walls, creating high pressure in the area. Like a balloon inflating, the veins swell, become tortuous, and begin to compress surrounding tissues. This pooled deoxygenated blood prevents the removal of toxins and continuously stimulates nerve endings, causing that well-known “persistent pain.”

What are the risk factors in the development of venous congestion?

We know that this syndrome does not affect everyone equally. Some individuals are more prone to this pooling due to their vascular structure. In women especially, the complexity of the vascular network in the pelvic region and hormonal cycles make this area the epicenter of the disease. Our genetic inheritance, lifestyle, and physiological processes we go through all play a decisive role in vascular health.

The main factors that increase the risk of venous congestion are:

• Genetic predisposition
• Having multiple childbirths
• Hormonal imbalances
• Excess weight
• Sedentary lifestyle
• Occupations requiring prolonged standing
• Polycystic ovary syndrome

How do pregnancy and hormones affect the process of venous congestion?

Pregnancy is the most significant process that triggers venous congestion syndrome. Your body undergoes a miraculous transformation during pregnancy, but this change comes at a considerable cost to the veins. First, to nourish the baby, blood volume in the body increases by nearly sixty percent. This massive fluid load challenges the capacity of veins that are already delicate.

At the same time, hormones come into play. Pregnancy hormones relax muscles and connective tissues to allow comfort for the baby and flexibility in the birth canal. However, these hormones also relax the vessel walls. As the veins relax, they dilate, and the valves within them can no longer meet properly.

Mechanical factors should not be overlooked. The growing uterus physically compresses the main veins within the abdomen. This pressure prevents blood from the legs and pelvis from moving upward, much like stepping on a hose. Even after childbirth, although this pressure disappears, the veins that have stretched like a “worn-out elastic” and the damaged valves may not return to their original state. That is why the majority of our patients are women who have had at least one or two childbirths.

How do patients describe pain caused by venous congestion?

The pain associated with this condition is not a sharp, stabbing pain like appendicitis or kidney stones that drives you to the emergency room. It is more insidious, more exhausting, and “wearing.” Patients often cannot pinpoint the exact location of the pain, saying things like “my entire lower abdomen hurts” or “there’s a heaviness inside me.”

The most characteristic feature is that the pain changes throughout the day. You may feel light as a feather when you wake up in the morning because, while lying down during the night, blood has easily returned to the heart and the veins have emptied. However, once you get up and start your day, gravity comes into effect. As the hours pass, standing and doing daily tasks causes the veins to fill and stretch. By evening, the pain can become unbearable.

The most common characteristics of the pain are:

• Dull and throbbing in nature
• A feeling of fullness in the groin area
• Aching that radiates to the lower back and hips
• Worsening in the evening hours
• Increase with prolonged standing
• Relief when lying down and resting
• Severe cramps during menstrual periods

What are the externally visible signs of venous congestion?

Although the condition is known as “internal varicose veins,” it can sometimes give outward signals, like the visible tip of an iceberg. A careful observer may notice abnormal vein enlargements in certain areas of the body. These signs are strong evidence that the problem is not limited to the legs but extends higher into the abdomen.

Varicose veins seen especially in the groin area or external genital region are reflections of pelvic pressure. Many women notice these varices during pregnancy; although they may decrease somewhat after childbirth, they may not disappear completely. These veins are not just a cosmetic issue but a sign of what is happening internally.

Signs that can be noticed externally or that affect neighboring organs include:

• Vulvar varices
• Varicose clusters on the inner thigh
• Dilated veins behind the buttocks
• Recurrent hemorrhoid attacks
• Frequent urge to urinate
• Burning sensation during urination
• Abdominal bloating and gas

How are sexual life and psychology affected by venous congestion?

Perhaps this is the most difficult topic to discuss, yet the most distressing for our patients. Venous congestion is not only a physical pain but also an emotional burden. The excessive filling of veins in the pelvic region can cause significant pain during and after sexual intercourse. Blood flow to the area naturally increases during intercourse, but the dysfunctional veins cannot drain this blood. As a result, a throbbing pain may persist for hours after intercourse, sometimes even into the next day.

Over time, this leads patients to withdraw from sexual activity, experience communication issues with their partner, and suffer a loss of self-confidence. While chronic pain alone already predisposes individuals to depression, the addition of sexual dysfunction further isolates the patient.

Worse still, when patients consult doctors with these complaints, standard examinations often reveal nothing, and they are frequently told that “the problem is psychological” and sent home. However, their pain is real, physical, and has an anatomical basis. Being treated as if they are “hypochondriacs” is one of the most exhausting aspects of this process.

Why is venous congestion often diagnosed late or overlooked?

There is a rule in medicine: “You cannot diagnose what you cannot see.” The biggest obstacle in diagnosing venous congestion lies in how standard imaging methods are performed. When you undergo ultrasound, CT, or MRI, the technician typically has you lie flat on your back.

As soon as you lie down, the effect of gravity disappears. The large varicose veins that swell with blood and cause significant discomfort when standing empty and collapse when you lie down. The radiologist sees normal vessel diameters on the screen and assumes everything is fine. Your report comes back “normal,” yet your pain persists. This paradox is the main reason for delayed diagnosis.

To make the diagnosis, the physician must “suspect” this condition. During Doppler ultrasound examination, having the patient strain (Valsalva maneuver) is critical. During straining, intra-abdominal pressure increases, and if reflux is present, reverse blood flow can be detected as a color change on the screen. However, the most definitive diagnostic method is “venography,” performed in an angiography unit, where contrast material is injected into the vein and flow is observed in real time.

The methods used in diagnosis include:

• Transvaginal Doppler Ultrasonography
• Standing venous Doppler
• MR Venography
• CT Venography
• Catheter Venography

How are Nutcracker and May-Thurner syndromes related to venous congestion?

Sometimes the problem is not just in the valves of the ovarian veins; there may be an issue higher up, on the main highway. If we think of venous congestion as a lake overflowing, sometimes the reason is that the river draining the lake is blocked. As interventional radiologists, we must look not only at the lake but also at those rivers.

“Nutcracker Syndrome” involves the left renal vein. This vein passes between the aorta and another artery. In some individuals, this space is very narrow, and the renal vein becomes compressed like a nut in a nutcracker. When blood cannot pass through, it seeks an alternative path and flows backward under pressure into the left ovarian vein, causing large varices in the pelvis.

Similarly, in “May-Thurner Syndrome,” the main vein of the left leg is compressed by the right iliac artery against the spine. This leads to both swelling in the left leg and a feeling of fullness in the pelvic region. The presence of these syndromes completely changes the treatment plan. If we attempt to treat only the varices below without addressing the compression above, symptoms may persist or even worsen.

Symptoms of these anatomical compression syndromes include:

• Occult blood in the urine
• Left-sided flank pain
• Swelling in the left leg
• Unilateral leg varicose veins
• A sensation of pelvic fullness

Is non-surgical treatment of venous congestion possible?

In the past, the only option for women suffering from these severe pains was major surgical operations. Often, the pain was thought to originate from the uterus, leading to the removal of completely healthy organs. Unfortunately, there are countless patients whose pain persisted even after hysterectomy because the issue lies not in the organ but in the surrounding vascular network.

Today, thanks to “Interventional Radiology” techniques, treatments without incisions, stitches, or general anesthesia are possible. The treatment is called “Transcatheter Embolization.” While this term may sound unfamiliar, its principle is simple: to close the problematic vein that is leaking and causing pain from within.

This is not a surgical operation. No incision is made in the body. The procedure is performed by entering the vein through a tiny puncture, no larger than a needle hole. Patients can return home the same day and do not need to interrupt their daily lives. The main goal is to eliminate the faulty vein where deoxygenated blood pools, allowing blood to flow through healthy pathways.

How is venous congestion treated during the embolization procedure?

On the day of the procedure, the patient is taken to the angiography suite. A millimetric entry is typically made into a vein in the groin or neck under ultrasound guidance. The entry site is numbed with local anesthesia, similar to a dental procedure, so only that area is desensitized. The patient remains awake, can communicate with us, and can even watch their vessels on the screen.

After gaining access, we navigate through the vascular system using very thin plastic tubes (catheters), about the thickness of a hair. First, we perform detailed mapping. We identify which veins have reflux, how they connect, and visualize everything by injecting contrast material. Once the problematic vein is identified, it is time to close it.

For this, special occlusive materials are placed inside the vein. The goal is to seal the vein permanently. The procedure usually takes between 45 minutes to 1 hour, and when it is completed, only a small bandage is placed over the entry site.

The occlusive materials used in treatment include:

• Metallic coils
• Vascular plugs
• Sclerosing foam
• Tissue adhesives

Does closing a vein cause problems for blood flow in venous congestion?

The most common concern and question from patients is: “If you close that vein, how will the blood flow? Is that vein there for no reason?” This is a very valid question, and the answer should reassure you.

The vascular network in our body is like the side streets of Istanbul. When main roads are blocked, navigation systems redirect you through alternative routes. The same applies to the circulatory system. The vein we close is already a “faulty road”; it does not carry blood back to the heart but instead allows it to flow backward and pool. In other words, it is no longer functional and is harming the body.

When we close this faulty pathway, blood flow is automatically redirected to alternative routes—healthy veins that function properly. The body has an incredible capacity for collateral circulation. Therefore, we are not blocking circulation; on the contrary, we prevent blood from entering a “dead end” and ensure it flows through healthy pathways. This procedure does not impair blood supply to the ovaries or uterus; the organs continue to be nourished and function normally.

What can patients expect after venous congestion treatment?

After the procedure, patients are observed in the ward for about 2 to 4 hours. At the end of this period, they can be discharged walking. They can return to their normal lives the next day and resume desk work. As long as they avoid heavy lifting or strenuous exercise, there are no restrictions on daily activities.

However, there is one important point we always emphasize: “Post-Embolization Syndrome.” In the first few days after the procedure, some temporary symptoms may occur due to the reaction of the treated veins. This is actually the body’s way of saying, “I am resolving and repairing the issue here,” and is a sign that the treatment is working. These symptoms are not complications or abnormalities.

Possible experiences in the first few days after the procedure include:

• Mild fever
• Nausea
• Flank pain
• Menstrual-like cramps
• Fatigue
• Lower back pain

What is the success rate of treatment for venous congestion?

The technical success rate of this treatment performed with interventional radiology methods is quite high. In other words, locating and closing the vein is a routine and safe procedure for us. The more important factor is clinical success—whether your pain improves.

Scientific studies and our clinical experience show that with proper patient selection and accurate targeting of the affected veins, symptoms significantly decrease or completely resolve in 85–90% of patients. However, this is not a magic wand; one should not expect the pain to disappear instantly.

Recovery is a process. The shrinking of varices, resolution of edema (swelling), and relief of nerve endings take time. Patients usually begin to feel improvement after their first menstrual cycle. By the end of the first month, we often hear feedback such as “that evening heaviness is gone.” Full recovery and maximum effect are typically observed between the 3rd and 6th months.

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez is one of Türkiye’s leading interventional radiology and neuroradiology specialists, focusing on minimally invasive endovascular treatments. His primary areas of expertise include aneurysm and stroke treatments, embolization procedures, non-surgical treatments of thyroid and parathyroid diseases, interventional oncology, and peripheral vascular interventions. He currently serves as the Head of the Interventional Radiology and Neuroradiology Department at Istanbul Memorial Göztepe Hospital.
Graduating from Istanbul University Cerrahpaşa Faculty of Medicine in 1997, Prof. Dr. Kılıçkesmez received advanced training in interventional radiology and oncology as a Clinical Fellow at London Guy’s & St Thomas’ and King’s College Hospital between 2012 and 2013. He earned the title of Professor in 2020 and, in the same year, became the Founding Interventional Radiologist at SBÜ Çam and Sakura City Hospital. He also holds the EBIR (European Board of Interventional Radiology) certification.
Prof. Dr. Kılıçkesmez has 94 international and 40 national publications and over 2500 citations. He serves as a reviewer for prestigious journals such as the American Journal of Roentgenology (AJR) and Diagnostic & Interventional Radiology. With his clinical and academic expertise, he is a nationally and internationally recognized authority in stroke treatment, brain aneurysm, embolization, tumor ablation, and minimally invasive treatments of thyroid/parathyroid diseases.