The role of pelvic venous reflux and vasoactive neuropeptides in the development of chronic pelvic pain in patients with pelvic venous disease

• Grishenkova A.S.
• Karalkin A.V.
• Mishakina N.Yu.
• Vasilyeva G.Yu.
• Gavrilov S.G.

Abstract

Objective. This study was undertaken to investigate the effect of pelvic venous reflux (PVR) and the activity of vasoactive neuropeptides on the development of chronic pelvic pain (CPP) in patients with pelvic venous disease (PeVD).

Patients and methods. Our prospective cohort study sequentially included 110 patients with PeVD and 20 volunteers (healthy women). Amongst patients with PeDV, 70 had a symptomatic form of the disease (i. e., there were complaints of CPP, hypogastric discomfort, dyspareunia) and 40 had an asymptomatic form (i. e., with no clinical manifestations of PeVD). Patients underwent a clinical examination, duplex ultrasound scanning (DUS) of pelvic and lower-limb veins, as well as single-photon emission computed tomography (SPECT) of pelvic veins with in vivo labelled red blood cells. The frequency of reflux in pelvic veins, its duration and the degree of blood deposition in the varicose veins of the pelvis were assessed. Volunteers underwent only a clinical examination and DUS. All the 130 participants underwent enzyme immunoassay of blood plasma to determine the levels of calcitonin-gene-related peptide (CGRP) and substance P (SР).

Results. According to DUS, reflux in the gonadal veins (GVs) was found in 45.7% of patients with symptomatic PeVD, and only in 10% of asymptomatic patients (p=0.001). Reflux duration in GVs in symptomatic patients was 4.1±1.7 s and in asymptomatic patients – 1.4±0.3 s (p=0.002). There were no statistically significant differences in the diameters of GVs with reflux among patients with symptomatic and asymptomatic PeVD. Similar data were obtained by comparing the duration of reflux in parametrial veins (PVs) and their diameters. Reflux in GVs for more than 2 s was found in 41.4% of symptomatic patients and only in 5% with asymptomatic PeVD (p=0.001). In patients with CPP, reflux in the GVs, PVs and uterine veins (UVs) was detected in 24.2%, in the GVs and PVs in 45.7%. In 90% of patients without CPP, reflux was detected only in the PVs. Pronounced pelvic venous congestion was found in 95.7% of patients with CPP and in 15% of patients without CPP (p=0.001) according to SPECT. CGRP and SP levels in symptomatic patients significantly exceeded those in asymptomatic patients (CGRP – 0.48±0.06 ng/ml vs 0.19±0.02 ng/ml, respectively, p=0.001; SP – 0.38±0.08 ng/ml vs 0.13±0.03 ng/ml, respectively, p=0.001).

Conclusion. Reflux in the pelvic veins for more than 2 s, involvement of more than 1 pelvic venous collector in the pathological process, combined with an increase in the levels of CGRP and SP in blood plasma, can be considered as hemodynamic and neurobiological factors in the development of CPP in patients with PeVD.

Keywords:pelvic venous disease; chronic pelvic pain; calcitonin gene-related peptide; substance P