Sometime about a year ago, I had three new patients coming in with the same complaint: Chronic pelvic pain that felt like an achey pressure. Worse in standing and after sex, much like a prolapse — but not responding to classic prolapse treatment.
One was diagnosed, but didn’t know what the fuck to do about it.
Do you treat pelvic congestion syndrome? she asked.
I didn’t. I panicked, and impulse-bought a course to further educate me on the matter.
That course was one of those experiences where you learn something, begin to see it in so many places you missed before, and just can’t unsee it: pelvic venous disorders (PeVD), the larger group of conditions including pelvic congestion, May-Thurner Syndrome, and Nutracker Syndrome.
Often, cases are not straightforward or have complex presentations, which is why the current recommendation is to refer to any and all symptoms as PeVD. It’s a cute umbrella term!
The medical weeds get thick quickly. So let’s dig in and figure out wtf PeVD is, who might be at risk, and what to do if you suspect you may have it. And obvi, this isn’t medical advice!
PeVD is incredibly common and under-diagnosed (fun!), and should be ruled out if you have either given birth and/or have any kind of chronic pelvic pain.
Primary symptoms of PeVD are pelvic pressure, painful sex, blood in urine, low back/flank pain, and leg swelling.
The gold standard treatment of PeVD involves vascular surgical approaches including stenting and embolization of affected vessels, and should always be tailored to the client.
Conservative therapy includes movement, breath work, and reducing compensation patterns to optimize blood flow within the affected vessels. This is a really solid option if you’re not ready for more invasive approaches and/or want to have a future pregnancy.
The case of the hellfire bladder. On interstitial cystitis, which can cruise along with PeVD symptoms. (You might want to see this one on urge incontinence, too!)
“Will my vagina fall out?” An ode to pelvic organ prolapse. The pressure a lot of folks feel can immediately get read as prolapse, and sometimes the two conditions can co-occur. It’s good to know the difference!
Hypermobility syndromes + pelvic floor ishes. On Ehlers Danlos Syndrome and hypermobility. For movement support with hypermobility, I wrote this one for you!
Okay, let’s start with basics: What the fuck is PeVD, exactly? What’s happening anatomically?
Tbh, my head starts to spin getting into the specifics of vascular disorders. I am a muscle, bone, and fascia girl; vessels are not my jam. So let’s keep this hella simple and digestible!
A vein’s walls can become weakened in one location, creating an opportunity to for blood to pool.
A vein’s valve can malfunction, creating blood flow in the opposite direction of where it’s supposed to go. This is called reflux, and it’s the most common driver of PeVD symptoms. The blood pools with gravity, and the distended vein can create fascial discomfort and/or nerve irritation.
A vein can also become compressed due to a nearby artery pressing on it, creating an obstruction (like a kink in a hose or whatever tube analogy makes you happy).
Generally, the left side is more at risk for ishes due to structural anatomy reasons (a longer vein, a weirder angle) on the renal, iliac, and ovarian veins. Which brings me to symptoms!
PeVD is wildly common, and affects 15-20% of people assigned female at birth between the ages of 20-50. Read that again. Among those with chronic pelvic pain, the estimated incidence increases to 30-45%.
left flank pain (although this could happen on the right side, it’s just less likely!)
blood in urine
sudden urges to pee and/or painful urination
dull, achey pain and pressure in the pelvis and lower abdomen that is worse after being on your feet, exercise, or sex (again, think about blood pooling!)
increased dull pain during menstruation
pain gets worse throughout the day, and isn’t present when you wake up
Here’s another cute image. I like this one because it shows the direction of blood flow, and how this can go wrong. See that whole plexus of veins at the bottom of the pelvis? It would feel uncomfy if there were a lot of blood chilling out down there!
Remember that venous blood should be flowing towards the heart, so in the abdomen and pelvis, that’s up, not down!
Okay, cool. So here’s the thing: these symptoms, while distinct, are vague and sneaky AF. Particularly if you don’t have blood in your urine (which many people do not), PeVD can cosplay as prolapse in postpartum people, and — shocker! — a huge risk factor for PeVD is pregnancy! It can also disguise itself as urge incontinence or interstitial cystitis (see: urinary urgency and painful peeing).
Other folks who tend to get PeVD? Those with Ehler’s Danlos Syndrome (EDS) and POTS (postural orthostatic hypertension syndrome) — there is thought to be a connection between the connective tissue dysfunction of the vessel walls, and it was recently hypothesized that PeVD may be a driver for POTS symptoms in some folks.
There are also associations with interstitial cystitis, long COVID, and dysautonomia, although these are generally case reports, and no solid research has been done on the mechanism of why this might be.
And — most interestingly to me, Jennifer Lanoff, WHNP-MSCP recently wrote this excellent article about her clinical observations of endo clients presenting with PeVD symptoms after endo excision surgery. She also wrote another very thorough follow up here connecting the dots from PeVD to vulvodynia, which I highly recommend!
Soooooo, yeah. It’s easy to miss. And not a lot of people treat it, or know how to diagnose it.
Try on your tightest pair of compression leggings for a few hours, assuming you have some laying around. Does this make your symptoms better?
Lay in some kind of inversion for 15ish minutes. This could be as simple as laying on the floor with your shins on a couch! Does this make your symptoms better?
If you answered yes to both of the above, it may be worth pursing further assessment. Look for an interventional radiologist, vascular surgeon, or urogynecologist specializing in PeVD. Yes, I know I gave you three specialties, and that’s confusing. But the realreal is that you want to find someone in one of these professions who really knows their shit, has referral partners in other departments, and loves to treat PeVD.
Depending on the type of symptoms or veins that are in question, you may need MR venography and/or a specialized intravaginal ultrasound to make an accurate diagnosis. You want to find a specialist who knows what to look for.
In her amazing course, Dr. Julie Baron recommends the following strategies for improving PeVD symptoms without surgical intervention:
improving breath patterns
improving thoracic expansion
improving pelvic outlet expansion
For my clinician pals, I seriously recommend this course, and no, I’m not getting paid to say that!
Wtf does this mean? If you’re concerned about PeVD symptoms, simply beginning by improving your breath mechanics and pelvic range of motion can do a lot.
My fan fave way to do this is to lay over a pillow, like so:
From this position, imagine your favorite person in the world has their hand on the back of your rib cage and pelvis, and breathe into that person’s hands.
You can also expand the pelvic outlet by doing a “rock back” from a lateral knee down lunge position, like this:
From this position, inhale as you allow your body to shift back in space while keeping your sit bones wide apart (hence the butt shot), the exhale back to the start position shown here. You may not go very far, and that’s cool!
TBH, these two practices are some of my faves for most folks, so honestly, you can’t go wrong!
Deep breath, friend. PeVD can feel overwhelming, and to be real, we barely touched the surface here. In crazy news, I recommend reaching out to your local pelvic floor clinician (we are nice!) if you would like more movement and biomechnical-based support with PeVD symptoms.
As always, I am rooting for you. And I love hearing from you! Leave a comment below or respond to this email. I respond to every one.
Adventures in Vaginas (and other parts) is my labor of love, dedicated to you.
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