Self-perceived quality of life after pelvic organ prolapse reconstructive mesh surgery: prospective study

Objective

To assess the self-perceived quality of life in women with advanced pelvic organ prolapse before and after mesh surgery.

Study design

Women with symptomatic pelvic organ prolapse (stage III–IV according to pelvic organ prolapse quantification (POP-Q)) were invited to participate in the study. All enrolled patients underwent prolapse surgery using the transvaginal mesh technique. Success was defined as ICS POP-Q stage 0 and I. The SF36v2 questionnaire was used as a subjective outcome measure.

Results

113 patients were available for follow-up at 6–8 weeks and 16–18 months. Overall anatomic success rates were 87.6%. Statistically significant improvements in the self-perceived quality-of-life were found in 3 individual domains (general health (GH), vitality (V) and mental health (MH)) and in one summary domain (MCS) at 6–8 weeks post-op. In one individual and one summary domain (role – physical (RP) and physical component summary (PCS)) the scores were significantly lower. At the end of the study statistically significant improvement was observed in four out of eight individual domains (vitality (V), menthal health (MH), physical functioning (PF), social functioning (SF)) as well as in both summary scores (PCS and MCS).

Conclusions

Reconstructive mesh surgery improved significantly various self-perceived quality of life dimensions. Therefore, women should expect significant improvement in their general quality of life after this type of operation. The assessment of urogenital well-being should be a routine attitude when counseling menopausal women.     

Persistent pelvic pain following transvaginal mesh surgery: a cause for mesh removal

Objective

Persistent pelvic pain after vaginal mesh surgery is an uncommon but serious complication that greatly affects women's quality of life. Our aim was to evaluate various procedures for mesh removal performed at a tertiary referral center in cases of persistent pelvic pain, and to evaluate the ensuing complications and outcomes.

Study design

A retrospective study was conducted at the University Hospital of Caen, France, including all patients treated for removal or section of vaginal mesh due to pelvic pain as a primary cause, between January 2004 and September 2009.

Results

Ten patients met the inclusion criteria. Patients were diagnosed between 10 months and 3 years after their primary operation. Eight cases followed suburethral sling procedures and two followed mesh surgery for pelvic organ prolapse. Patients presented with obturator neuralgia (6), pudendal neuralgia (2), dyspareunia (1), and non-specific pain (1). The surgical treatment to release the mesh included: three cases of extra-peritoneal laparoscopy, four cases of complete vaginal mesh removal, one case of partial mesh removal and two cases of section of the suburethral sling. In all patients with obturator neuralgia, symptoms were resolved or improved, whereas in both cases of pudendal neuralgia the symptoms continued. There were no intra-operative complications. Post-operative Retzius hematoma was observed in one patient after laparoscopy.

Conclusions

Mesh removal in a tertiary center is a safe procedure, necessary in some cases of persistent pelvic pain. Obturator neuralgia seems to be easier to treat than pudendal neuralgia. Early diagnosis is the key to success in prevention of chronic disease.     

Successful treatment of refractory endometriosis-related chronic pelvic pain with aromatase inhibitors in premenopausal patients

Objective

Not every patient with endometriosis responds to currently recommended conventional medical treatment regimens. The objective of this study was to determine the efficacy and side effects of aromatase inhibitors in the treatment of premenopausal patients with endometriosis associated with chronic pelvic pain refractory to conventional treatment.

Study design

Four premenopausal patients with documented refractory endometriosis and chronic pelvic pain were treated with aromatase inhibitors, either anastrazole (3) or letrozole (1), for 6 months. The treatment was combined with calcium 1.5 g per day and vitamin D 800 U per day. The main outcome measure was reduction in pelvic pain assessed by visual analogue scale. Side effects were documented and changes in serum LH, FSH and 17-β estradiol and bone density (Dexa scan) were measured before, during and after treatment.

Results

There was marked improvement in pelvic pain in the four patients. Their mean pain score fell from 9 prior to treatment to 4.5 at the end of treatment. One patient with infertility conceived immediately after completing the treatment. There were no changes in the hormone levels and bone scan scores. The most common side effect was irregular bleeding with anastrazole and joint pains with letrozole.

Conclusions

Aromatase inhibitors are beneficial in premenopausal women with chronic pelvic pain secondary to refractory endometriosis without compromising fertility and with minimal side effects. Further cohort and comparative studies are needed to confirm these observations.     

Vaginal reconstructive surgery for severe pelvic organ prolapses: A ‘uterine-sparing’ technique using polypropylene prostheses

Objective

The Ulmsten's “Integral Theory” for pelvic floor dysfunctions is based on the need to reinforce fascias and ligaments with prostheses to obtain a reconstitution of the pelvic floor's anatomy. In September 2004 we developed a “uterine-sparing” surgical technique to correct such pathologies and in this paper we present results obtained. Primary outcome was to evaluate the technique's efficacy, secondary outcomes the resolution of stress urinary incontinence, postoperative pain (VAS scale), safety and complications.

Study design

This prospective study included patients affected by stage 3 and 4 uterine-vaginal prolapse who wished to conserve their uterus. Those with (1) minor degrees of severity, (2) unfit for surgery, (3) with a clear indication to hysterectomy (i.e. endometrial cancer), (4) with an elevated operative risk (American Society of Anaesthesiologists—ASA score III and IV), (5) previous vaginal surgeries and (6) with moderate/severe defecation problems were excluded. The technique consisted in a sacrospinous colposuspension with polypropylene mesh. The pelvic status was classified according to the international Pelvic Organ Prolapse staging system (POP-Q). Postoperative pain was scored with the VAS Scale. All patients were given the King's Health questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Wexner questionnaire.

Results

From September 2004 to November 2006 we treated 80 patients. Polypropylene prostheses (Gynemesh-Soft PS, 10 cm × 15 cm – GyneMesh, Gynecare Ethicon – Somerville, NJ, USA) were used to reconstruct the pubo-cervix or the recto-vaginal fascia. We performed an anterior-central vaginal reconstruction in 35 (43.8%) patients, central-posterior in 25 (31%) and total reconstruction in 20 (25%). The median follow-up was 21 months (range 18–26). The severe pelvic prolapse, evaluated with the POP-Q System, was completely treated in all the patients and no recurrences were observed. The urodynamic examination showed a complete resolution of the stress urinary incontinence in 10 patients (83%). Sexual activities improved in all patients. We recorded three vaginal erosions and one patient complained of a postoperative dyspareunia.

Conclusions

This pilot study suggests that our technique is safe and effective and can efficiently repair the pelvic organs prolapse, without undergoing hysterectomy and with a low rate of vaginal erosions.     

Risk factors of surgical failure following transvaginal mesh repair for the treatment of pelvic organ prolapse

Objective

To identify the factors associated with pelvic organ prolapse (POP) recurrence after transvaginal mesh (TVM) repair.

Study design

One hundred and thirteen women with symptomatic POP stage II to IV were scheduled for TVM procedures. All subjects underwent urinalyses and pelvic examination using the POP quantification (POP-Q) staging system before and after surgery.

Results

Seven (6.2%) of 113 women reported POP recurrence after a mean follow-up time of 30 months. We performed a univariate analysis of patients’ characteristics to identify the predictors of surgical failure after TVM. There was no difference between two groups as to body mass index, POP stage, mesh type, and preoperative urinary symptoms and urodynamic parameters (P > 0.05). However, we found that uterine prolapse (P = 0.016) and surgical experience (P = 0.043) were two significant predictors of surgical failure. Multivariate logistic regression showed similar results.

Conclusion

Advanced uterine prolapse and lack of surgical experience were two significant predictors of failure following TVM. POP recurrence after mesh repair appears to be unlikely beyond the learning curve.     

Effect of tamoxifen on extracellular signal-regulated kinases in the urethra of castrated female rats

Objective

To explore the role of primary physicians in the diagnostic delay of lower urinary tract and pelvic organ prolapse symptoms in parous women.

Study design

Prospective cohort study of women referred to the Urogynecology Outpatient Clinic of a major medical center by primary physicians in the community for initial assessment of lower urinary tract and pelvic organ prolapse symptoms.

Results

Most of the women blamed themselves for the delay. However, the primary physicians were considered responsible for 33.5% of the delays. There was no between-group differences in self-blame (p = 0.438). Women with pelvic organ prolapse blamed the gynecologist significantly more often than women with lower urinary tract symptoms (p = 0.043); 38.6% of the physicians considered the symptoms not sufficiently severe or a natural part of aging.

Conclusion

Patients need to receive more information on the availability of specific evaluations and treatments for pelvic floor dysfunction.     

Reutilization of the Prolift mark system for the simultaneous correction of prolapse and incontinence in patients with pelvic organ prolapse and stress urinary incontinence

Objective

The reutilization of the Prolift™ system with the simultaneous creation of a midurethral sling from the same set was described.

Study design

The technique was applied in 23 patients with pelvic organ prolapse (POP) and clinically evident or occult stress urinary incontinence (SUI).

Results

Correction of POP was achieved in 21 out of 23 (91.3%) patients, and complete continence after the surgery in 20 out of 23 (86.9%). There was a significant improvement in voiding symptoms without deterioration of voiding function. Morbidity of the surgery was not different from that with Prolift™ alone.

Conclusion

Modification of the method with creation of a suburethral sling from the same set is more economically viable without compromising either pelvic organ support or continence.     

Robotic technology for pelvic exenteration in cases of cervical cancer

Background

Cervical cancer represents one of the most common types of neoplasia among women; the use of minimally invasive techniques in the treatment of cervical cancer is a challenge.

Objectives

To present evidence regarding robotic technology in the performance of pelvic exenteration in cases of cervical cancer.

Search strategy

PubMed and Scopus databases were searched.

Selection criteria

Articles examining the use of robotic technology for pelvic exenteration in cases of cervical cancer were included.

Data collection and analysis

Four studies were included.

Main results

Most cancers treated with robotic-assisted pelvic exenteration were squamous cell carcinomas of the cervix. The stage of primary cancer ranged from IB2 to IVA. In 7 of the 8 patients, anterior pelvic exenteration was performed; the other patient underwent total pelvic exenteration. Procedure duration ranged from 375 to 600 minutes; blood loss was 200–550 mL. Postoperative complications occurred in 2 of the 8 patients and included perineal abscess, Miami pouch fistula, and ureteral stenosis. Postoperative hospital stay ranged from 3 to 53 days, and postoperative follow-up ranged from 2 to 31 months.

Conclusions

The gold standard for pelvic exenteration remains the open surgical approach; however, the application of robotic technology could be an alternate choice associated with excellent results.     

Letrozole and norethisterone acetate in colorectal endometriosis

Objective

Up to now limited attention has been given to the medical treatment of bowel endometriosis. This study evaluates the efficacy of aromatase inhibitors and norethisterone acetate in treating pain and gastrointestinal symptoms caused by bowel endometriosis.

Study design

This prospective pilot study included six women with colorectal endometriosis; all women had intestinal nodules infiltrating at least the muscularis propria of the bowel and did not have a stenosis of the bowel lumen >60%; the patients suffered from pain and intestinal symptoms. The study subjects received letrozole (2.5 mg/day) and norethisterone acetate (2.5 mg/day) continuously for 6 months. The presence and intensity of symptoms were evaluated before starting the treatment, and after 3 and 6 months of treatment.

Results

The double-drug regimen improved pain, non-menstrual pelvic pain, deep dyspareunia, dyschezia, symptoms mimicking diarrhoea-predominant irritable bowel syndrome, intestinal cramping, abdominal bloating and passage of mucus in the stools, and 67% of the patients declared that the treatment improved their gastrointestinal symptoms.

Conclusions

The administration of letrozole and norethisterone acetate reduces pain and gastrointestinal symptoms of women with colorectal endometriosis, particularly when patients suffer from symptoms mimicking diarrhoea-predominant irritable bowel syndrome.     

Peritoneal tuberculosis mimicking ovarian cancer

Objective

To evaluate the clinical and urodynamic outcomes of transvaginal mesh repair (TVM) for the treatment of pelvic organ prolapse (POP).

Study design

One hundred and twenty-four women with POP stage II to IV were scheduled for a TVM procedure. Preoperative and postoperative assessments included pelvic examination, urodynamic testing, and a personal interview about urinary symptoms using a standard questionnaire.

Results

We found a significant improvement at points Aa, Ba, C, Ap, and Bp (P < 0.001) except for total vaginal length (P = 0.08), and the overall success rate was 93.5% (116/124). Various urinary symptoms improved significantly following TVM (P < 0.01). In addition, residual urine, functional urethral length, and the rate of detrusor overactivity, improved significantly after surgery (P < 0.05). Apart from vaginal erosion (14/124; 11.3%), the rates of other surgical complications were acceptably low.

Conclusion

TVM is an effective procedure for the treatment of POP and urinary symptoms, this being possibly related to postoperative release of urethral obstruction. Vaginal erosion is less likely to occur beyond the learning curve.     

Embolización de las arterias uterinas como alternativa de tratamiento para miomas uterinos. Experiencia en 60 pacientes

Introduction

Uterine fibroids are the most common benign solid tumors of the female genital tract. Uterine artery embolization (UAE) is presented as an alternative to surgical treatment.

Objective

To evaluate the efficacy of UAE in the management of symptomatic fibroids, establish the success rate, and evaluate the safety of the technique by detecting complications during the procedure.

Material and methods

A retrospective dual-center study was performed in 60 patients undergoing UAE from 2000 to 2011 in Albacete and the Puerta de Hierro General Hospital in Madrid.

Results

The clinical success of the technique was demonstrated in 41 of the 60 patients (overall success rate of 68% at 4 years of follow-up) Complications occurred in 7 of the 60 patients (11.6%), consisting of embolization syndrome and transient ischemic pain in the first and second, which resolved with medical treatment and without further complications.

Conclusion

UAE is an effective treatment for women with symptomatic fibroids, showing high reliability and a low rate of minor complications.     

Factores psicológicos en mujeres que padecen pelvialgia crónica grave operadas por laparoscopia o laparotomía

Purpose

To analyze the importance of psychological factors, understood as levels of anxiety and depression, among women with chronic pelvic pain and to evaluate the possibility of a relationship between these psychological factors and the persistence of pain after surgery.

Material and methods

We studied 41 women with chronic pelvic pain for more than 6 months who had undergone laparoscopy or laparotomy as a diagnostic-therapeutic method. The results in these women were compared with those in a control group of 86 women attending the clinic for bilateral tubal ligation. These patients were interviewed before surgery to evaluate their depression and anxiety levels using the Beck test and the STAI scale. The persistence of pain after surgery was assessed through a telephone survey.

Results

Levels of depression and anxiety were higher in the chronic pelvic pain group than in the control group but no differences were found in the trait anxiety variable. When interviews were carried out 3 months after surgery, the percentage of patients who continued to have postoperative pain was significantly higher in the chronic pelvic pain group than in the control group.

Conclusion

Quality of life is impaired in women experiencing pelvic pain for more than 6 months, due to increased levels of depression and state anxiety. Persistence of pain 3 months after surgery, despite elimination of its apparent gynecological cause, could be influenced by anxiety and depression.     

Initial experience of robotic anterior pelvic exenteration at a single institute

Objective

To present the initial experience with robotic anterior pelvic exenteration in patients with advanced pelvic cancer at Galaxy Care Laparoscopy Institute, Pune, India.

Methods

A retrospective chart review of data from 10 patients with advanced cervical carcinoma and bladder involvement or with vault recurrence following hysterectomy who were treated at the study hospital between November 2009 and May 2011. Clinicopathologic data and postoperative data including operative time, blood loss, blood transfusions, hospital stay, lymph node yield, and complications were recorded.

Results

The mean operative time was 180 minutes, the mean blood loss was 110 mL, and the mean duration of hospital stay was 5 days. There were no treatment-related morbidities or mortalities. A mean parametrial clearance of 3 cm with a distal vaginal margin of 3.5 cm was achieved. All patients had tumor-free margins. The mean number of harvested lymph nodes was 24. Six patients had positive lymph nodes on pathologic examination and were treated with chemoradiotherapy. At a median follow-up of 11 months, 8 patients were disease-free.

Conclusion

Robot-assisted anterior pelvic exenteration had favorable operative, pathologic, and short-term clinical outcomes. A large multicenter study is required to confirm the results.     

Selective salpingography: preliminary experience of an office operative option for proximal tubal recanalization

Objective

To evaluate treatment efficacy and patient acceptability of the new Radiographic Tubal Assessment Set (RTAS) (Cook Ireland Ltd., Limerick, Ireland) for selective salpingography (SSG).

Study design

33 women, between 23 and 38 years old, referred to the Fertility Centre of the Department of Obstetrics, Gynecology and Reproductive Science, Second University of Naples, for sterility problems, underwent an office operative SSG with the RTAS. Of the 33 women, 12 had bilateral tubal obstruction (Group A) and 21 had unilateral tubal obstruction (Group B). Patients who did not regain tubal patency were referred for laparoscopic surgery. To verify patient acceptability, a visual analogue score (VAS 1-10) of pain was completed immediately after the procedure.

Results

From a total of 45 obstructed fallopian tubes, 34 were recanalized, giving a success rate for the procedure of 75.6% (p < 0.001). Nine patients with bilateral tubal obstruction (Group A) had the tubes recanalized and five obtained a spontaneous pregnancy. Sixteen patients with monolateral tubal obstruction (Group B) had the tubes recanalized and nine obtained a spontaneous pregnancy. A total of seven patients were sent for operative laparoscopy: four of them had the tubes recanalized and two obtained a spontaneous pregnancy. One patient was lost to follow-up. The evaluation of the level of pain felt during the procedure on the 10 cm VAS showed mean pelvic pain 2.9 ± 2.2, and an incidence of no discomfort ± low pain significantly higher than moderate ± severe pain (p < 0.0001).

Conclusion

The RTAS can be considered a safe and effective tool to perform this office operative procedure for tubal recanalization, with a high acceptability for the patient. The “see and treat” approach in patients with proximal tubal obstruction (PTO) suggests for the future the use of this device under sonographic guidance, taking into account accurate patient selection.     

Incidence and Risk Factors for Pelvic Pain After Mesh Implant Surgery for the Treatment of Pelvic Floor Disorders

Study Objective

Our aim was to assess incidence and risk factors for pelvic pain after pelvic mesh implantation.

Rate,type, and cost of pelvic organ prolapse surgery in Germany,France, and England

Objective

To estimate the rate, type and costs of surgical interventions for pelvic organ prolapse (POP) in Germany, France, and England.

Study design

We identified the number, rate, and type of hospital admissions for pelvic floor surgery in 2005 from national hospital activity databases in each country: the German Hospital Episode, the French Medical Care Program Information System, and the National Health Service England Hospital Episode Statistics. Costs to the payer were estimated using the Diagnosis-Related Group reimbursement rates for each country.

Results

In 2005, the number (rate) of admissions for POP surgery was 36,854 (0.87 per 1000 women) in Germany, 36,679 (1.14 per 1000 women) in France, and 28,959 (1.13 per 1000 women) in England. Admissions for POP surgery constituted 10.4%, 16.7% and 16.9% of all admissions for female genital tract therapeutic interventions in Germany, France and England, respectively. At least 20% of hysterectomies were performed for the primary indication of POP. 57.4%, 45.0%, and 40.1% of all admissions for POP surgery included a hysterectomy. The costs to payers were €144,236,557, €83,067,825, and €81,030,907 in Germany, France, and England, respectively.

Conclusion

Burden and costs associated with POP surgery are substantial in the three countries studied. Thus, programs aimed at reducing the burden of this disease are desirable.     

Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations

Objective

Endometriosis is a chronic oestrogen-dependent gynaecological disorder, the most common symptom of which is pain. Inflammation can be considered one of the major causes of pain in endometriosis. In particular, degranulating mast cells have been found in significantly greater quantities in endometriotic lesions than in unaffected tissues. The increase in activated and degranulating mast cells is closely associated with nerve structures in painful endometriotic lesions. These observations indicate that inflammation due to mast cells may contribute to the development of pain and hyperalgesia in endometriosis. Controlling mast-cell activation may therefore relieve the pain associated with endometriotic lesions.

Study design

Four patients presenting an endometriosis-related pain intensity ≥5 (visual analogue scale for pain, or VAS) were enrolled and monitored during 3 months of the following treatment: oral palmitoylethanolamide 400 mg and polydatin 40 mg, twice daily for 90 days. Deep dyspareunia, dyschezia, dysuria, dysmenorrhoea and analgesic drug use during the 3-month follow-up period were also monitored, with the aim of demonstrating a reliable reduction in chronic pelvic pain.

Results

The preliminary results indicate that all patients enrolled experienced pain relief as early as 1 month after starting treatment. Furthermore, a reduction in the analgesic drugs usually employed for pain control was observed in all subjects treated. Additionally, some improvements in endometriotic lesions seemed to be demonstrated by imaging.

Conclusions

The palmitoylethanolamide–polydatin combination seems to be very useful in controlling chronic pelvic pain associated with endometriosis. As a result of these findings we have initiated a multi-centre pilot study to verify the effectiveness of this treatment in controlling the chronic pelvic pain associated with endometriosis.     

Real-time in vivo assessment of levator ani muscle deformation in women

Objective

To study the deformation of the levator ani muscle in vivo with the use of real-time ultrasound imaging of the pelvic floor.

Study design

Thirty-two women with symptoms of pelvic floor dysfunction underwent real-time in vivo assessment of the strain of the pelvic floor during Valsalva effort. All participants underwent clinical examination, urodynamics and 3D/4D translabial ultrasound scan of the pelvic floor. The deformation curves of the levator ani muscle were plotted and the difference in compliance according to the grade of urogenital prolapse was measured. One-way ANOVA and Spearman's correlation were used to test for significance of the relationship between variables (significance level P < 0.05). Test–retest analysis of the ultrasound measurements of the levator hiatal dimensions was also conducted using intra-class correlation coefficient (ICC).

Results

The deformation curve of the levator hiatus showed a non-linear relationship with gradually increased Valsalva force, which was quite pronounced in the pubourethralis subdivision of the levator ani muscle complex. Women with significant pelvic organ prolapse demonstrated a less compliant levator ani muscle close to its origin from the pubic bone than women with non-significant prolapse (median maximum strain 26% vs 32%, respectively, P = 0.03).

Conclusions

Real-time in vivo assessment of levator ani muscle deformation in women is feasible and yields significant information.     

Midterm prospective comparison of vaginal repair with mesh vs Prolift system devices for prolapse

Objective

To compare midterm clinical outcome using modified pelvic floor reconstructive surgery with mesh (MPFR) vs Prolift devices for the treatment of pelvic organ prolapse (POP).

Study design

This prospective observational cohort study involved 223 women with POP stages III–IV who were assigned to either MPFR (n = 131) or Prolift device (n = 92). Outcomes were analyzed at 6 and 12 months and the last follow-up visit postoperatively. Main outcome measures included pelvic organ prolapse quantification measurement, Short Form-20 Pelvic Floor Distress Inventory (PFDI-20), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) questionnaires, perioperative outcomes, complications, and a personal interview about urinary and sexual symptoms. Statistical analysis included comparison of means (Wilcoxon test or Student's t-test) and proportions (Chi-square test). Multivariate analysis was carried out using Cox proportional hazard model.

Results

At follow-up (median, 36 months; range, 17–58 months), anatomic success for MPFR and Prolift was 87.07% and 93.41%, respectively (P = 0.1339). Both operations significantly improved quality of life, and PFDI-20 scores were lower in the Prolift group than the MPFR group (P = 0.03). Complication rates did not differ significantly between the two groups and the prevalence of urinary symptoms decreased postoperatively in both groups. The cost of operation, however, was RMB ¥11,882.86 yuan for MPFR and ¥23,617.59 yuan for Prolift (P = 0.00).

Conclusions

MPFR and Prolift had comparable anatomic outcomes, Prolift had better functional outcomes than MPFR, but MPFR is much cheaper than Prolift. MPFR is an alternative, cheap and effective surgical treatment option to mesh-kits for the management for POP.     

Embolization to treat pelvic congestion syndrome and vulval varicose veins

ObjectiveTo evaluate the efficacy of embolization for treating the symptoms of pelvic congestion syndrome (PCS).MethodsTwenty-one women with PCS who were treated with embolization at Radboud University Nijmegen Medical Centre between 2003 and 2008 were sent a questionnaire about their symptoms before embolization, 2 months after the first embolization, and at the time the survey was conducted.ResultsAll patients completed the questionnaire. Two months after the first embolization, 14 (66.7%) women had some degree of improvement of symptoms. Nine (42.9%) patients underwent a second embolization. At the time the survey was conducted, 16 (76.2%) patients had some degree of improvement of symptoms. In addition to improvements in varicose veins and pelvic pain, there was improvement of hemorrhoids.ConclusionEmbolization of pelvic varicosities may be an effective treatment in a well-selected group of patients with PCS. If there is no improvement of symptoms after initial embolization, a second procedure is unlikely to be effective.