PeVD round 1

Delphi Study on Pelvic Venous Disorders - Information for Participants

Dear colleague,

We invite you to be part of an expert panel on pelvic venous disorders and ask you to fill out the first round of our Delphi study. The survey will take approximately 20–25 minutes to complete. Your responses will remain confidential and aggregated results will be shared with all panel members. Those who complete all rounds and contribute to consensus formation will be acknowledged as members of the "Delphi PeVD Expert Panel" in the final publication.

But first, we shall introduce the reason for this study. Pelvic venous disorders (PeVD) represent a spectrum of venous reflux and/or obstruction within the ovarian, uterine, internal iliac, renal and/or pelvic plexus veins, resulting in numerous complaints (1). The complaints of pelvic pain are frequently presented to a gynaecologist, the venous congestion is primarily offered to the vascular surgeons, and the treatment and diagnosis are often left to the interventional radiologist. A major challenge is that these disciplines often do not speak the same language.

Historically, the spectrum of PeVD was described using terms such as pelvic congestion syndrome (PCS), Nutcracker syndrome, May–Thurner syndrome and others (2,3). Recent consensus efforts by the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the Society of Interventional Radiology (SIR) have redefined this spectrum under the SVP classification (Symptoms–Varices–Pathophysiology) to uniform nomenclature, improve phenotypic description and move beyond territory-based or symptom-only terminology (1,2).

Within the SVP framework, PeVD are further differentiated according to their underlying hemodynamic mechanism, reflux (V3 phenotype) or obstruction (V2 phenotype), under the pathophysiology (P) domain (1). These mechanisms may coexist within the same venous territory but represent distinct pathophysiologic processes with different clinical presentations, diagnostic findings and therapeutic strategies (1).

Reflux-dominant disease typically reflects intrinsic valvular incompetence of the ovarian or uterine venous plexus and corresponds to what is often referred to as PCS, although the term PCS has historically been applied inconsistently to other pelvic venous phenotypes as well. Because this reflux phenotype is frequently associated with gynaecological symptoms and is most managed by endovascular embolisation of the refluxing ovarian veins/internal iliac tributaries veins, the present Delphi study will focus exclusively on this subgroup.

In contrast, obstruction-dominant disease arises from impaired venous outflow, most often due to iliac or renal vein compression (May–Thurner or Nutcracker syndromes) or post-thrombotic changes, and may secondarily give rise to reflux through collateral pathways. The SVP classification recognizes such secondary reflux as a compensatory decompression mechanism rather than primary reflux disease (1).

For consistency, the reflux-dominant phenotype will hereafter be referred to as the ovarian/uterine reflux–insufficiency phenotype (PeVD V3) throughout the questionnaire and related text.

This Delphi study aims to reach expert consensus among specialists in gynaecology, vascular surgery, interventional radiology and angiology regarding the nomenclature, diagnostic criteria, and differential diagnostic frameworks for PeVD V3. Where appropriate, the findings and their presentation will be aligned with the SVP classification to ensure consistency with current international terminology. The study will also address additional domains that extend beyond the SVP framework, reflecting the broader multidisciplinary perspective needed for a comprehensive evaluation of PeVD V3.

For participants who have not previously been involved in a Delphi process, the purpose is to build consensus among experts on a set of statements derived from the existing literature and from preliminary focus-group discussions. Participants will be asked to indicate their level of agreement with each statement and, where relevant, to provide a brief explanation of their reasoning. Statements that do not achieve consensus, defined as a minimum of 70% agreement, will be revised and recirculated in the next round, together with a summary of feedback from the panel. Consensus is usually achieved within three to four rounds, although in some cases a final round may take place as a digital focus group to resolve remaining points of disagreement.

Section A. Nomenclature

Consistency in terminology is essential for cross-study comparability and multidisciplinary communication.

Section B. Chronic pelvic pain (CPP)

The European Association of Urology (EAU) defines CPP as persistent or recurrent pain perceived in pelvic structures (6). For nociceptive pain that becomes persistent, a duration of at least 3 months is generally required, while cyclical pain may warrant a longer threshold of more than 6 months (6). The International Association for the Study of Pain (IASP) defines CPP as pain perceived in the pelvic region for at least 6 months (7). According to Khan et al. (StatPearls, 2024), CPP is typically established following 3–6 months of persistent pelvic pain (8).