Pelvic Congestion Syndrome without Venography: A Pragmatic Pathway Using Doppler Ultrasound, Laparoscopy and Ligation in Resource-Limited Settings

Abstract

Background: Pelvic congestion syndrome (PCS) is an under-recognised cause of chronic pelvic pain and a frequent driver of diagnostic wandering, particularly in low- and middle-income countries (LMICs). Recent adoption of the SVP (Symptoms-Varices-Pathophysiology) framework and more structured imaging pathways can shorten time to diagnosis and treatment. Objective: To illustrate an SVP-harmonised, resource-adapted diagnostic–therapeutic pathway that resolves pain and ends diagnostic wandering. Case presentation: A 42-year-old grand multipara (G9P9009) with >6-month non-cyclical pelvic pain and post-coital exacerbation underwent a stepwise work-up. Transvaginal duplex ultrasonography (TVUS) was used as the gatekeeper test; cross-sectional venous imaging and selective venography were not available. Persistent symptoms and high clinical suspicion led to diagnostic laparoscopy with planned concomitant intervention. Laparoscopy revealed parauterine varicosities consistent with venous reflux phenotype. Transperitoneal ligation of the culprit veins was performed in the same session. A venoactive agent was prescribed post-operatively for 30 days. The patient experienced complete resolution of pelvic pain and dyspareunia on follow-up, effectively terminating a prolonged diagnostic odyssey. Conclusion: In settings where venography and endovascular therapy are limited, a graded pathway SVP-guided clinical phenotyping, standardised TVUS, and diagnostic-therapeutic laparoscopy is a pragmatic alternative that can deliver rapid, patient-centred benefit. Embolisation remains first-line where available; laparoscopy is a viable “when necessary” option. Prospective LMIC studies with harmonised outcomes are urgently needed.