Pelvic Congestion Syndrome: Pelvic Varices

5/13/2018

Pelvic congestion syndrome is denoted as chronic pelvic pain in women who have varicose veins in or near their ovaries within the pelvic cavity.  Pelvic congestion syndrome is a common cause of chronic pelvic pain, but many times is overlooked as a cause for the pelvic pain.  In women that have pelvic varicose veins and venous insufficiency pelvic pain is a complaint, however, may not have any symptoms at all.  It remains a medical mystery as to why some women develop pain and other symptoms, yet others have no complaint at all.  The majority of women diagnosed with pelvic congestion syndrome normally fall within the 20-45 year age demographic and have had multiple pregnancies.

Physician have noted that chronic and acute pelvic pain from these enlarged veins,  primarily develops after pregnancy, and the pain level from this trends upward and seems to worsen with each subsequent pregnancy.  Typically, this type of pelvic pain is a dull ache, however, it may be reported by the patient as an acute, sharp, stabbing, or throbbing type of pain.   Some patients have stated that it seems to worsen at the end of the day, or after sitting/ standing for long periods of time.  Pelvic pain from pelvic varices can also occur during or after sexual intercourse, and may be accompanied by low back pain, aches in the legs, and abnormal menstrual bleeding.   In addition, some women may also have varicose veins in the vulva, vagina, perineal area, buttocks, thighs, and lower legs.  And as if these symptoms weren’t enough, some women experience a clear or watery discharge from the vagina, fatigue, mood swings, headaches, abdominal bloating, painful ovaries and cervical pain with motion tenderness.

Diagnosing Pelvic Congestion Syndrome

In the clinical diagnosis and documentation of pelvic congestion syndrome, a diagnosis can be made using non-invasive ultrasound testing, or by a diagnostic pelvic laparoscopy.  Ultrasound is the diagnostic tool most commonly used and many OB physicians perform both an abdominal and a transvaginal duplex ultrasound in the office as the first-line testing .  These ultrasounds may be enough to enable the provider to see if there is a pelvic varicosity within the pelvic area, and if venous enlargement and/or venous reflux is causing the patients’ pelvic pain.   Unfortunately ultrasound may not show pelvic varices, or pelvic veins well, especially when the patient is lying down, or is obese.  Ultrasound does not produce good images in patients that are obese as the sound waves do not travel through adipose tissue as well as they do in non-obese patients.  

If ultrasound does not diagnose or confirm the pelvic congestion syndrome, additional testing such as venography, CT, MRI, magnetic resonance venography may be necessary to confirm the pelvic varicosities diagnosis.  If venography is performed, contrast dye tests may be utilized for better imaging and real time viewing.  If non-invasive procedures do not give the provider a good confirmed diagnosis of pelvic congestion syndrome, then the option of a diagnostic surgical pelvic laparoscopy may be the next choice for diagnosis confirmation. 

When Pelvic Congestion Syndrome occurs pelvic pain is one of the first symptoms, however, clinically,  the same effect happen to the pelvic veins , similar to development of varicose veins that develop in other areas of the body, such as in the perineal, vulvar and groin area, and the upper and/or lower extremities.  The physiology behind this, is the vein valves in the veins no longer function normally, causing blood to back up within the vein, therefore becoming enlarged,  engorged or “congested”.  This “congestion” is what causes the pain.

Treatment for pelvic congestion syndrome

OB providers may treat pelvic congestion syndrome with oral drug therapy, such as NSAIDS (nonsteroidal anti-inflammatory drugs) which can reduce pain, decrease fever, prevent blood clots and, reduce inflammation.  At this time, aspirin, ibuprofen, and naproxen sodium, can be purchased over the counter, but many NSAIDs, such as ketorolac tromethamine, celecoxib, meloxicam and many others still requires a prescription from the provider.  Usually  the first line treatment is nonsteroidal anti-inflammatory drugs, as nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve the pain.  If NSAIDs are ineffective, the provider may prescribe a suppression of ovarian function and prescribe oral or injected hormone therapy.  It is also becoming more and more common for providers to refer patients out for non-traditional medical therapies for pain relief such as acupuncture therapy, physical therapy, bio-feedback training, and yoga meditative therapy in addition to traditional medical therapy. 

 

If the above treatments fail, the next option is a minimally invasive surgical option which involves stopping blood flow to the varicose veins using  a procedure called known as venous embolization. The procedure requires an overnight stay in hospital, and is done using a local anesthetic or conscious sedation, and has a fairly high success rate.

Currently there are two procedures are available:

·         Embolization of a vein: After using an anesthetic to numb a small area of the thigh, doctors make a small incision there. Then, they insert a thin, flexible tube (catheter) through the incision into a vein and thread it to the varicose veins. They insert tiny coils, sponges, or glue-like liquids through the catheter into the veins to block them.

·         Sclerotherapy: Similar to embolization, a catheter is inserted into the vein, and the provider injects a sclerosing solution through it and into the varicose veins. The solution blocks the vein(s).  It is assumed that when blood can no longer flow into the varicose vein(s) in the pelvis, the pain usually lessens.

Coding Considerations:

Scenario 1 - For pelvic congestion syndrome

A diagnostic venogram is obtained from a right common femoral venous puncture, with selective catheterization and diagnostic venography of the left renal vein, left ovarian vein, bilateral hypogastric veins, and bilateral external iliac veins. A large, varicose left ovarian vein is shown with reflux into enlarged uterine veins. The left ovarian vein is embolized with coils and sotradecyl.

CPT Codes:

·         37241: Venous embolization

·         36012X3: Selection of left renal/ovarian, left hypogastric, left external iliac veins

·         36011: Selection of right hypogastric vein

·         75822-59: Bilateral extremity venogram

·         75831-59: Left renal/ovarian venogram

ICD-10cm Codes

·         N94.89 Other specified conditions associated with female genital organs and menstrual cycle

·         I86.2 Pelvic varices

·         R10.2 Pelvic and perineal pain

Scenario 2 - Pelvic congestion syndrome, persistent unimproved pelvic pain despite bilateral gonadal vein embolizations

Moderate sedation was employed using Versed and Fentanyl titrated for patient comfort by a trained independent observer. Continuous physiologic monitoring vital signs was performed for approximately 105 minutes.

Lidocaine was administered locally. A small dermatotomy was made and a micropuncture needle was placed into the right internal jugular vein. Ultrasound guidance was used. A hardcopy image was saved. An 0.018" wire was easily passed. A micropuncture sheath assembly was advanced and a Benson guidewire was then advanced into the IVC.

A 6 French sidearm sheath was then placed into the IVC.

Using AP venous catheter, the right internal iliac vein was catheterized contrast was injected to confirm position. The catheter was then advanced over a wire into the main trunk draining pelvic varicosities. A 1 cc Foley catheter was then advanced over an exchange length Bentson guidewire and the balloon was insufflated proximally 0.3 cc of dilute contrast to include flow. Approximately 5 cc of contrast was then gently injected to fill numerous large pelvic varicosities. Access was then gained into the left internal iliac vein and contrast was injected. A 1 cc Fogarty catheter was then placed into the left internal iliac vein and contrast was injected following insufflation of the balloon. Access was regained into the right internal iliac vein varicosity. The portable gland was insufflated to occlude flow and 3 cc of 3% Sotradecol was then administered as a sclerosing agent. This was allowed to dwell for 5 minutes. Repeat venogram was performed which demonstrated decreased size of varicosities.  The catheter was removed and manual compression was used to achieve hemostasis.

FINDINGS:

1.    Initial right internal iliac vein venogram demonstrates numerous large varicosities in the pelvis. The majority of these are present inferiorly. Treatment was performed only of the more inferior varicosities. Post sclerotherapy venogram demonstrates significant decrease in size of varicosities.

2.    Left internal iliac vein venogram demonstrates several mildly enlarged pelvic veins. These are much less impressive than noted on the right.

CPT Codes:

·         36470 Injection of sclerosing solution; single vein

·         75822 Venography, extremity, bilateral, radiological supervision and interpretation

·         36012 (rt int iliac) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus)

·         36012 (lt int iliac) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus)

ICD-10cm Codes

·         N94.89 Other specified conditions associated with female genital organs and menstrual cycle

·         I86.2 Pelvic varices

·         R10.2 Pelvic and perineal pain

Billing/Reimbursement Issues

Some 3^rd party payers may consider venous embolization or pelvic venous sclerotherapy of the ovarian or internal iliac veins as experimental, unproven or not medically necessary.  If the provider and patient wish to have this procedure performed, a pre-authorization and patient/insurance policy review should be performed before the procedure is scheduled.   If the insurance carrier does not consider these procedures as medically valid, or necessary be sure to have the patient sign an advanced beneficiary notice and collect payment as appropriate for your practice.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.