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Pelvic Venous Disorder (PeVD) is an umbrella term encompassing chronic venous abnormalities in the pelvis, including venous insufficiency, obstruction, reflux, or compression. It manifests clinically as chronic pelvic pain and is often under-recognized, particularly in women of reproductive age.
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PeVD includes:
Schematic classification of pelvic venous disorders (PeVD). (A) Type Ia: unilateral venous insufficiency, Type Ib: bilateral venous insufficiency; (B) Type IIa: May-Thurner syndrome, Type IIb: nutcracker phenomenon, Type IIc: both IIa and IIb; (C) Type IIIa: common iliac vein obstruction, Type IIIb: inferior vena cava obstruction; (D) Type IV: arteriovenous malformation or fistula. Type IId (extrinsic compression), IIIc (portal hypertension), and V (nutcracker Syndrome) are not displayed.
Rezaei-Kalantari K, Fahrni G, Rotzinger DC, Qanadli SD. Insights into pelvic venous disorders. Frontiers in Cardiovascular Medicine. 2023;10. doi:https://doi.org/10.3389/fcvm.2023.1102063
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Symptoms-Varices-Pathophysiology (SVP) discriminative instrument for pelvic venous disorders. The SVP instrument allows precise classification of a given individual with a pelvic venous disorder, based on their symptoms, location of their varices as well as the anatomical segment(s) involved, hemodynamic process in each segment (reflux or obstruction), and causative etiology in each segment (thrombotic, nonthrombotic, or congenital vascular malformation). The S and V domains locate the pelvic symptoms and varices on the basis on 3 pelvic zones arranged in descending order: Zone 1, the level of the left renal vein and the left renal venous plexus of connected veins (reservoir); Zone 2, the gonadal and internal iliac veins and the pelvic venous reservoirs; and Zone 3, pelvic origin extrapelvic veins, including vulvar and scrotal veins, as well as pelvic origin lower extremity varicose veins (previously known as “atypical varices”). The veins or the lower extremity are considered Zone 4. Symptoms and varices may exist in more than 1 zone, and SVP can account for this. After classifying the patients’ symptoms and the location of their varices, the underlying pathophysiology can be described. Because several anatomical levels may also be involved, the hemodynamics and etiology in each can be accounted for with the classification system as follows: S1, 2, and/or 3 V1, 2, and/or 3, PA1H1E1, A2H2E2, ….
Drawing, courtesy of Melissa Schumaker Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2021;9(3):568-584. doi:https://doi.org/10.1016/j.jvsv.2020.12.084
Khilnani NM, Winokur RS, Marvel RP, Meissner MH. Pelvic Venous Disorders in Women: 5-Year Update from a Society of Interventional Radiology Foundation–Sponsored Research Consensus Panel. Journal of Vascular and Interventional Radiology. 2025;36(1):9-16. doi:https://doi.org/10.1016/j.jvir.2024.09.010
Examples of patients with venous origin chronic pelvic pain with pelvic varices and their SVP Classifications:
| Pathophysiology causing venous origin chronic pelvic pain | SVP classification |
|---|---|
| Left ovarian vein reflux, uncompensated | S2V2PLGV,R,NT |
| Left and right ovarian vein reflux, uncompensated | S2V2PBGV,R,NT |
| Left ovarian and right internal iliac vein reflux, uncompensated | S2V2PLGV,R,NT; RIIV,R,NT |
| Left common iliac vein obstruction, and compensating left internal iliac vein reflux | S2V2PLCIV,O,NT; LIIV,R,NT |
| Left renal vein obstruction, and compensating left ovarian vein reflux | S2V1,2PLRV,O,NT; LGV,R,NT |