Pelvic Vein Syndrome: Expert Interview with Dr. med., Dipl. oec. med., FESC Michael Lichtenberg

Dr. med. Dipl. oec. med. Michael Lichtenberg is a recognized specialist in the field of angiology and, as chief physician of the Department of Angiology at Hochsauerland Hospital, heads the Center for Pelvic Vein Obstructions in Arnsberg. The Arnsberg Center is one of the largest specialized departments in Germany for the treatment of pelvic vein disorders.

With his many years of experience in treating venous and arterial vascular diseases, Dr. Lichtenberg has earned an excellent reputation both nationally and internationally. His particular focus is on the diagnosis and treatment of complex pelvic vein disorders, for which he and his team perform several hundred minimally invasive procedures each year. Modern imaging methods and catheter techniques are used to provide targeted and gentle care for patients with symptoms such as swelling, chronic pain, or open leg ulcers.

Another key area of Dr. Lichtenberg’s medical practice is the treatment of critical circulatory disorders of the extremities, particularly in the context of peripheral arterial occlusive disease. To this end, a dedicated research center has been established at the facility, where innovative endovascular procedures are tested and scientifically monitored. The long-term care provided to patients by a specialized team ensures a particularly high standard of care. Dr. Lichtenberg is also actively involved in the further development of his field: As managing director and future president of the German Society of Angiology, he advocates, among other things, for new guidelines and the promotion of young medical professionals. His work embodies modern, evidence-based vascular medicine at a high clinical and scientific level.

The editorial team of the Leading Medicine Guide spoke with Dr. Lichtenberg about pelvic vein syndrome and learned more about its difficult diagnosis and successful treatment.

Pelvic vein syndrome is an often-underestimated cause of chronic symptoms in the pelvic and leg regions that primarily affects women—but can also occur in men. This venous disorder is characterized by impaired blood outflow from the pelvic veins, triggered by compression, narrowing, or post-thrombotic changes. The result is venous stasis, which can lead to symptoms such as chronic pelvic pain, swelling, varicose veins, or a feeling of heaviness in the legs. Because the symptoms are nonspecific, pelvic vein syndrome often goes undetected for a long time. However, modern imaging techniques and minimally invasive treatment options now enable a precise diagnosis and effective therapy—with the goal of significantly improving the quality of life for those affected. Pelvic vein syndrome results in chronic blood stasis, which can lead to swelling, pain, varicose veins, or even open leg ulcers. Common causes include congenital narrowings, scarring from thrombosis, or external compression—for example, by adjacent vessels or structures such as an artery (in May-Thurner syndrome). 

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May-Thurner syndrome—also known as Cockett syndrome—is a venous outflow disorder caused by compression of the left pelvic vein (Vena iliaca communis sinistra) by the right iliac artery (Arteria iliaca communis dextra) running over it. This anatomical constriction can lead to chronic obstruction of venous return from the left leg and, consequently, to various symptoms. The left iliac vein runs beneath the right iliac artery—this anatomical crossing is present in all people. In May-Thurner syndrome, however, the angle is particularly unfavorable, or the surrounding tissue is so tight that it causes permanent narrowing of the vein. Over the course of years, the pulsatile pressure from the artery can lead to thickening and damage to the vein wall.

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Since the symptoms are often nonspecific, pelvic vein syndrome is frequently diagnosed late. Modern imaging techniques such as ultrasound, CT, or MRI, as well as venous pressure measurements, help confirm the diagnosis. Treatment is usually minimally invasive and involves the placement of a stent to permanently improve venous outflow.

“Pelvic vein syndrome is a condition that primarily affects women—the ratio is approximately 70% women to 30% men. Those affected often report severe pain in the lower abdomen that can radiate to the groin and down into the legs. A particularly notable feature is that this pain intensifies significantly during the perimenstrual period—that is, around the time of menstruation. In addition, there is often severe pain during sexual intercourse, which frequently leads to relationship conflicts. In many cases, patients also experience discomfort when urinating—known as dysuria—or pain during urination. The cause of these symptoms is a constriction of the pelvic vein, usually on the left side. Anatomically speaking, in humans, the left pelvic vein runs beneath the right pelvic artery—exactly where the two vessels meet in front of the fifth lumbar vertebra. If the space at this junction is too narrow, a kind of “competition” arises: The artery, which pulses more forcefully, compresses the underlying vein. As a result, blood flow is disrupted—the venous blood backs up. You can think of it like a garden hose: If you pinch the hose at the front, the water backs up—with cheap hoses, the pressure can become so great that they burst at the back. In women, nothing bursts, but the resulting backflow creates massive pressure in the vein. And this high venous pressure—because the blood cannot drain properly—ultimately leads to intense pain in the lower abdomen. This is what’s known as pelvic vein syndrome,” explains Dr. Lichtenberg at the start of our conversation, continuing:

“People often ask whether this is also accompanied by swelling in the legs—for example, whether patients can no longer stand comfortably. This can happen, but it’s not necessarily the case. When it does occur, it typically affects the left side, usually starting around the ankle. Those affected notice significant pain in the left leg when standing or walking, especially during physical exertion. You can think of it like a balloon that keeps getting inflated: Blood constantly flows into the leg via the artery, but the return flow through the vein is blocked. This rising venous pressure puts pressure on everything—tendons, nerves, muscles—and thus causes pain that can sometimes be unbearable. It’s hard to say how long it takes for symptoms to become noticeable; this varies greatly from person to person. For some, it develops slowly over the course of years; others notice earlier that “something isn’t right.” So it’s not possible to make a general prediction about when the distress will become so severe that a medical evaluation is sought—but that is precisely what is crucial with such symptoms.”

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Pelvic vein syndrome particularly affects middle-aged women, especially after pregnancies. In many cases, the syndrome is caused by a congenital or acquired compression or narrowing of the pelvic veins. 

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In clinical practice, the diagnosis of pelvic vein syndrome involves several steps and typically begins with a detailed medical history and a physical examination. Patients often report nonspecific symptoms such as swelling, a feeling of tightness, or pain in the pelvic and leg areas, which tend to worsen especially when sitting or standing.

“A woman who complains of chronic pain in the lower abdomen usually goes to a gynecologist first. The gynecologist routinely examines the ovaries, the uterus, and the vagina, and performs an ultrasound—but the pelvic veins are usually not the focus of attention. Many gynecologists also don’t know what to make of the presence of numerous varicose veins in the pelvis. Yet these typically develop due to increased venous pressure: The affected veins dilate—similar to varicose veins in the legs—because blood cannot drain properly. And this is precisely what often goes undiagnosed for years. As a result, many patients initially receive misdiagnoses. A classic example is endometriosis. It’s not uncommon for doctors to even suggest removing the uterus—on the assumption that this might alleviate the symptoms. However, diagnosis is extremely challenging, as symptoms can actually be very similar across various conditions. In addition to endometriosis, these include adenomyosis—endometriosis within the uterus—as well as nerve-related conditions such as pudendal neuralgia, in which the pelvic nerves are irritated. Cysts, hemorrhages, or other gynecological changes can also cause similar pain. As a result, patients undergo multiple surgeries or examinations—such as laparoscopy—without the underlying cause being identified. Even modern imaging techniques such as MRIs do not always provide answers, because often the pelvic veins are simply not examined. “The radiologist must specifically look for this narrowing—if he does not, the problem remains invisible,” explains Dr. Lichtenberg.

MRI or CT scans are generally capable of visualizing these changes. The key is the clinical question—that is, what you’re looking for. 

Dr. Lichtenberg comments on this: “Specialists are often focused on their own field—which I self-critically refer to as ‘blinkered diagnostics.’ They often fail to look beyond their own specialty. Yet it is precisely this exchange—between gynecology, radiology, gastroenterology, and general surgery—that is crucial. After all, ‘diffuse abdominal pain’ can have many causes—and only those who think broadly can make the correct diagnosis. To make the narrowing visible, gadolinium is used as a contrast agent in MRI, and an iodine-containing agent in CT. The affected vein is still functioning—it’s just constricted at a specific point. You can visualize it like a dog bone: Before the narrowing, the vein is its normal width; in the middle section, something constricts it; and afterward, it widens again. It is precisely there, at the narrowing, that blood pools—which leads to the typical symptoms. The actual treatment, of course, is only initiated after a confirmed diagnosis. For this, the symptoms must be clear: If a patient reports severe pain that significantly impairs their quality of life—for example, when playing with their children, in their relationship, or at work—then there is an indication for therapy. The next step would then typically be a specialized MRI scan with venous imaging. Patients bring the images with them, and if the symptoms and imaging findings match, targeted treatment can be initiated—for example, through a catheter procedure.”

The treatment of pelvic vein syndrome primarily involves minimally invasive procedures specifically designed to restore unimpeded blood flow in the pelvic veins. 

“Pelvic vein syndrome is not a life-threatening condition: it does not lead to amputations or serious complications such as ‘black leg.’ However, once the diagnosis has been made clinically and confirmed by MRI, the therapeutic option is to open the narrowed pelvic vein using a stent. This procedure is performed minimally invasively via the femoral vein. First, the puncture site is locally anesthetized; the surgeon then inserts a catheter and injects contrast dye to precisely visualize the narrowing on an angiogram. An intraluminal ultrasound probe is then advanced: it measures the length and diameter of the stenosis with millimeter precision, allowing a precisely fitting stent to be selected. Before inserting the stent, the narrowing is carefully dilated with a balloon; only then is the metal scaffold inserted, which keeps the vessel permanently open and prevents it from collapsing again. Occlusion of the affected vein would not be an option—unlike in the case of ovarian vein insufficiency, where blood flows retrograde into the pelvis due to defective valves. The pelvic vein, on the other hand, is the main drainage vessel of the leg; ligating it would inevitably lead to severe thrombosis. In Germany, the stent procedure is performed on an inpatient basis. The patient is admitted on the day of the procedure, monitored overnight, and can usually be discharged the following morning. After the procedure, only mild wound or back pain typically occurs, and a return to normal daily activities is possible after just a few days. “Since the stent is a relatively large metal scaffold, there is a risk of thrombosis; therefore, consistent anticoagulation with a modern oral blood thinner is required during the first three months to reliably prevent clot formation within the implant,” Dr. Lichtenberg explains.

The prognosis for treatment of pelvic vein syndrome is generally very good—especially when the diagnosis is made early and treatment is performed by a specialized center. 

Minimally invasive procedures such as stent implantation lead to a lasting improvement in symptoms in over 90 percent of cases. Many patients report noticeable relief from typical symptoms—such as swelling, a feeling of tightness, pain, or chronic leg fatigue—shortly after the procedure. “The prognosis for stent implantation in cases of pelvic vein stenosis is generally good, but patients need to have realistic expectations. This is not an immediate ‘quick-fix’ procedure in which a single intervention suddenly makes all symptoms disappear. Rather, patients have typically been suffering from this chronic venous insufficiency for many years. During this time, pronounced venous bypass circuits and varicose veins have developed in the pelvis. Stent implantation sustainably reduces pressure in the venous system, causing these dilated vessels to gradually regress. This, in turn, leads to a gradual alleviation of symptoms. Patients should be informed that it may take several weeks—sometimes two to three months—before a noticeable improvement is felt. Symptoms generally subside gradually. Complete relief from symptoms is possible but cannot be guaranteed, as individual responses to the procedure may vary. Regarding the long-term stability of the stent: Even though it is a robust, permanent implant, it remains a foreign body in the body. As with other medical implants—such as pacemakers or coronary stents—there is always a residual risk, for example, of restenosis (recurrence of narrowing) or occlusion. The venous stents used are relatively large (about 14 mm in diameter), and according to current findings, the rate of stent occlusion is less than 5% over a five-year period. “To detect potential complications early, it is recommended to have a follow-up ultrasound examination at least once a year,” advises Dr. Lichtenberg.

The treatment aims not only to eliminate venous congestion but also to stabilize the function of the venous valves and prevent secondary damage such as skin changes or leg ulcers. This usually leads to a significant improvement in quality of life: mobility increases, physical performance improves, and many patients can once again manage their daily lives without symptoms. In the long term, patients also benefit from the fact that the therapy reduces the risk of recurrent thrombosis or the progression of chronic venous disease. However, careful follow-up care is essential for sustained therapeutic success; this includes not only regular clinical monitoring but also ultrasound examinations and, if necessary, adjustments to compression therapy.

Dr. Lichtenberg emphasizes: “In recent years, Karolinen-Hospital has developed into a leading European center for the diagnosis and treatment of pelvic vein syndrome. With over 400 documented and treated cases per year, the clinic has an exceptionally high level of experience in this field. Patients come not only from all over Germany, but also from other European countries and, increasingly, from regions such as the Middle East. In many of these countries—such as Saudi Arabia or the United Arab Emirates—this type of interventional therapy has so far been offered only rarely, if at all, which is why targeted training and collaborative projects with colleagues there are becoming increasingly important.”

When patients with recurrent or chronic lower abdominal discomfort, pain in the pelvis, or pain during sexual intercourse fail to receive a clear diagnosis over an extended period, this can be a significant burden—and it is not uncommon for a protracted diagnostic odyssey to begin. 

“While an internet search may reveal many personal accounts, it is no substitute for a structured medical evaluation. In principle, it is both correct and important to first rule out obvious causes, such as gynecological conditions like endometriosis or cysts. Other medical specialties, such as urology or gastroenterology, should also be considered, particularly in cases of nonspecific pelvic or flank pain. However, if no clear diagnosis can be made despite all investigations and the symptoms persist—especially in the case of typical symptoms such as cycle-related pain, discomfort during urination or sexual intercourse, and, if applicable, a sensation of swelling in the leg—it is strongly recommended to also consider an angiological examination. Specialists in angiology possess the necessary expertise to identify and classify vascular causes such as pelvic vein syndrome or May-Thurner syndrome. Although these conditions are not uncommon, they often go undiagnosed because they involve multiple disciplines and are frequently overlooked in traditional gynecological or radiological evaluations. Even though men are affected less frequently, they can suffer from comparable symptoms, such as in cases of severe venous drainage disorders. “The diagnostic and therapeutic approaches do not differ significantly in terms of methodology,” Dr. Lichtenberg concluded.

Thank you very much, Dr. Lichtenberg, for shedding light on this uncommon and often undetected condition!