A 37 year old woman complained of chronic perineal pain and numbness for three years. Physical examination was unremarkable, but perineal neurophysiological testing revealed isolated abnormalities of the left pudendal nerve. The distal motor latency and the left bulbocavernous reflex latency were both lengthened (5.3 ms; normal <3.5 ms and 48 ms; normal <42 ms, respectively). Previous laparoscopy for tubal ligation also described bilateral ovarian varices more prominent on the left side, which were confirmed at pelvic CT (fig 1A).
Figure 1 37 year old woman with left pudendal nerve compression by pelvic varices successfully treated with transcatheter ovarian vein embolisation. (A) Contrast enhanced CT scan through the ischial spine shows left ovarian varices (arrow). (B) Left ovarian vein phlebography shows dilated ovarian vein with congestion of the ovarian and uterine plexi (arrow) and filling of the pelvic veins across the midline. (C) Following embolisation, control phlebography demonstrates occlusion of left ovarian vein and reduction of pelvic varices (arrow).
Diagnosis of Alcock syndrome was rejected because pain was not exacerbated while seated, but rather in the upright position.1 Although perineal pain has not been reported in pelvic congestion syndrome,2 the possibility of venous compression resulting in nerve damage was raised. The patient was then referred to undergo an ovarian phlebography with possible subsequent embolisation.3 The phlebogram disclosed an enlarged left ovarian vein with congestion of the ovarian plexus (fig 1B) and selective left ovarian vein embolisation was performed with coils and glue (fig 1C). Three months later, our patient began to notice marked reduction in perineal pain and numbness. Neurophysiologial examination performed eight months after embolisation demonstrated normalisation of the left pudendal nerve distal motor latency.
This report suggests for the first time the possible compression of the pudendal nerve by pelvic varices, and should be analysed in line with other recently reported nervous compression cases of venous origin.4,5 It also demonstrates the dramatic relief obtained after ovarian vein embolisation.
References
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