Pelvic congestion syndrome diagnosis: ultrasound, venography and other tests

By the MALS Compass editorial teamPublished November 8, 2026Physician review: planned

Pelvic congestion syndrome is a cause of long-lasting pelvic pain linked to widened, backward-flowing veins in the pelvis. Finding it is not simple. There are no single agreed criteria, the symptoms look like many other conditions, and doctors usually make the diagnosis after other causes of pain have been ruled out [1][2]. In one review, the average time to diagnosis was reported as up to four years after the first visit [3].

This page explains which symptoms raise suspicion, which tests are used, what a pelvic congestion ultrasound measures, and what the results can and cannot tell you.

Key points

Ultrasound, often transvaginal (a probe placed in the vagina), is the usual first imaging test [4][5].
Doctors look at vein width, the direction of blood flow and how slowly blood moves; cut-offs differ between studies [2].
CT and MR venography show the veins in detail and can help find vein compression syndromes [6].
Catheter venography is the reference test and is usually done right before treatment [7].
Wide veins alone do not prove that they cause the pain [8].

Table of Contents

Why the diagnosis is hard

Pelvic pain has many possible causes, and the signs found on a physical exam are few [9]. Women with this condition are often seen by gynecologists, vascular specialists, pain specialists and gastroenterologists before the cause is found [7]. Laparoscopy (keyhole surgery to look inside the belly) is often used for pelvic pain, but it can miss widened veins, because the gas used to inflate the belly and the head-down position press the veins flat [4].

Symptoms that raise suspicion

Doctors think of pelvic congestion syndrome when a woman has [7][4]:

dull, aching pelvic pain for more than six months;
pain that is worse after standing or walking, and before periods;
pain during sex or an ache after sex;
bladder irritation or discomfort in the rectum.

Varicose veins of the vulva or varicose veins on the legs can also be a clue [3]. The condition occurs mostly before menopause, often after pregnancy [4].

Other causes to rule out

The work-up checks for other causes of pelvic pain first [10]. Endometriosis (tissue like the lining of the uterus growing outside it) causes very similar symptoms, and the two conditions often occur together [4]. In one MRI study of 52 women with chronic pelvic pain and confirmed pelvic varicose veins, 61.5% also had signs of endometriosis [11]. MRI can look for both problems in a single session [11].

Pelvic congestion ultrasound

Duplex ultrasound shows both the shape of a vein and the blood flow inside it. A transvaginal scan gives a close view of the veins around the uterus and vagina and of the ovarian veins [12]. A transabdominal scan (over the belly) is used to check the iliac veins [13].

Findings that studies use include:

What is measured	Values reported in studies
Width of pelvic varicose veins	more than 5 mm [10]
Width of the ovarian vein	more than 7 to 8 mm in one review [4]
Width of the pelvic veins (cut-off)	6 mm gave the best balance in one study where 40 women also had venography [14]; 7 mm was suggested by a meta-analysis [15]
Veins in the wall of the uterus	wider than 5 mm [4]
Blood flow speed	slow, less than 3 cm per second [4][2]
Backward flow (reflux)	reflux on bearing down (Valsalva maneuver), lasting 1 second or more in one study [14]

How accurate is it? A 2025 meta-analysis of 7 studies with 802 patients found that ultrasound correctly picked up 96% of cases and correctly ruled out 84% of women without the condition. The authors suggested a 7 mm vein width as the cut-off [15]. A narrative review notes that high-quality comparisons of these cut-offs are still few, and that formal ultrasound criteria do not yet exist [2].

CT and MR venography

CT venography and MR venography (MRV) are scans with contrast that show the veins of the belly and pelvis in detail. They help find compression syndromes and the paths blood takes around a blockage [6]. In one study of 50 women, CT and MRI found 14 cases with signs of vein compression; for this group, the authors found a stent followed by embolization the better option [16].

These scans have limits. In one center where 120 women had both, CT and MRV missed many faulty veins that catheter venography found, with MRV doing better than CT [17]. A fast MRI method without contrast has also been described [18].

Catheter venography: when it is used

In catheter venography, a thin tube is guided into the veins and contrast dye is injected while X-ray pictures are taken. It shows the flow in real time and is considered the gold standard [6]. Because it is invasive, it is usually done as the first step of the treatment session, right before ovarian vein embolization [7]. One study built an ultrasound score to help decide which women need venography [14].

If you are considering treatment, see our page on ovarian vein embolization.

Checking for nutcracker and iliac vein compression

Pelvic vein problems can be caused or worsened by a squeezed vein higher up:

In nutcracker syndrome the left kidney vein is pinched, and blood can be pushed down through the ovarian and pelvic veins. Diagnosis often combines ultrasound, CT or MRI and catheter tests, sometimes with pressure measurements inside the veins [19].
In iliac vein compression (May-Thurner syndrome) the main outflow vein of the pelvis is narrowed. In one study of 96 patients, belly ultrasound identified an iliac vein narrowing of 50% or more in 96%, checked against ultrasound from inside the vein [13].

Body position matters. In one study of 41 women, narrowing of the kidney and iliac veins seen while lying on the back often looked very different when the same women lay on their side or stood up [20].

What the results mean

In 2021 an international panel proposed the Symptoms-Varices-Pathophysiology (SVP) classification, which doctors may use to describe your findings. It describes three things: the symptoms, the varicose veins, and the underlying problem (which veins are affected, whether blood flows backward or is blocked, and why) [21]. It is used to describe patients more precisely and to compare research studies [21].

A diagnosis rests on symptoms and imaging together. Wide veins are common, and in one case-control study of 200 women with pelvic varicose veins, ovarian vein width did not differ between women with and without symptoms. A blocked outflow vein and leg varicose veins were more closely linked to symptoms [8]. If your results are unclear, it is reasonable to ask which further tests could help.

Questions to ask your doctor

Which other causes of my pain, such as endometriosis, have been ruled out?
Was my ultrasound done transvaginally, and did it check blood flow while I bore down?
What were the vein widths and flow findings, and how do they compare with the usual cut-offs?
Were my left kidney vein and iliac veins checked for compression?
Do I need CT or MR venography, or catheter venography, and why?

Learn more: our guide to pelvic congestion syndrome, ovarian vein embolization: what to expect, May-Thurner syndrome and nutcracker syndrome.

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