The Management of Pelvic Vein Incompetence in Women with Chronic Pelvic Pain

Abstract

Background Chronic pelvic pain is physically and psychologically debilitating. Pelvic vein incompetence may be a cause of chronic pelvic pain, but the available literature is insufficiently robust to inform clinical practice. This programme of study uses a mixed methods approach to answer several key research questions on how to manage pelvic vein incompetence in women with chronic pelvic pain. Methods The programme of study comprised several studies: a review of the available evidence pertaining to the management of pelvic vein incompetence in women with chronic pelvic pain; a modified Delphi study designed to define a consensus position amongst interventional radiologists as to the definition of the patho-anatomical features of pelvic vein incompetence; a case control study of the frequency of duplex-detected pelvic vein incompetence in women with chronic pelvic pain and in asymptomatic age and parity matched women, seeking to investigate an association between pelvic vein incompetence and chronic pelvic pain; a randomised controlled trial of transjugular embolisation in women with chronic pelvic pain and pelvic vein incompetence; an assessment of patient acceptability employing semi-structured interviews and qualitative analysis, based on the Theoretical Framework of Acceptability; and a mixed methods analysis of the lessons learnt from the programme of study. Results The literature review demonstrated that there is little high quality evidence to support clinical decision making in women with pelvic vein incompetence and chronic pelvic pain. In particular, studies of association between the two conditions and a randomised controlled trial of transjugular embolisation are urgently needed. The Delphi study found that consensus positions could be reached on the definition of pelvic vein incompetence and pelvic varices, and on the ‘gold standard’ imaging protocol. Interim data from the case control study suggests pelvic varices are strongly associated with pain, with pelvic vein incompetence showing an association of borderline statistical significance. Interim randomised controlled trial data showed that pain scores may be reduced at 12 months post-procedure in women who undergo embolisation, though rigorous statistical analysis was not possible. In general, patients perceived the case control study and the randomised controlled trial to be acceptable, though the patient survey used to collect pain score data and other outcomes was not considered to allow participants to accurately report their experiences. The assessment of ‘lessons learnt’ from the programme of study found that there are several considerations that should be made by future protocol designers when implementing studies of pelvic vein incompetence, particularly when deciding which type of gynaecology service patients may be recruited from. Conclusion This programme of study demonstrates that investigation of the management of pelvic vein incompetence is possible within the National Health Service, and that patients may benefit from investigation and treatment.

Date of Award	31 Dec 2019
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Charles Mccollum (Supervisor) & Ann-Louise Caress (Supervisor)