a Delphi study on PeVD/Pelvic Congestion

Step 1 of 9

11%

Name

This field is for validation purposes and should be left unchanged.

Dear colleague,

Thank you for participating in our Delphi study. If correct, you got the participant information folder as a PDF with the invitation email. If not, please download and read it here.

If you have any questions, please contact Drs. Naila Loudini, MD, PhD candidate, Gynecology and Obstetrics, Amsterdam UMC at n.loudini@amsterdamumc.nl.

Please agree with the below informed consent to start the Delphi questionnaire round 1

I have read the information letter. I was also able to ask questions. My questions have been answered satisfactorily. I had enough time to decide whether to participate.
I understand that participation is voluntary. I also understand that I can decide at any time not to participate or to withdraw from the study. I do not have to give a reason for this.
I give permission for my data to be collected and used in the manner and for the purposes described in the information letter.
I give permission to be contacted again after this study for a follow-up study.
I give permission for my data to be stored for 10 years after the conclusion of this study within Amsterdam UMC.

I agree to participate in this study(Required)

Yes, I agree

I give permission to be contacted again after this study for a follow-up research.

Yes, I agree

Which email address can we contact you on?(Required)

please use the same email address which was used to get our invitation

Delphi Study on Pelvic Venous Disorders - Information for Participants

Dear colleague,

We invite you to participate in an expert panel on pelvic venous disorders (PeVD) and to complete the first round of our Delphi study. The survey will take approximately 20–25 minutes. All responses will remain confidential; only aggregated results will be shared with the panel.

Participants who complete all Delphi rounds and contribute meaningfully to consensus formation will be acknowledged in the final publication as members of the “Delphi PeVD Expert Panel.” If any participant meets authorship criteria (e.g., substantial contributions to study design, data interpretation, manuscript development, completion of all Delphi rounds), co-authorship will be offered in consultation with the research team.

Pelvic venous disorders encompass a spectrum of reflux and/or obstruction within the pelvic venous system, involving the ovarian, uterine, internal iliac, renal and pelvic plexus veins. Because patients often present to different specialties, including gynaecology, vascular surgery, interventional radiology and angiology, terminology and diagnostic pathways have historically varied.

Traditional labels such as pelvic congestion syndrome, Nutcracker syndrome and May–Thurner syndrome have been used inconsistently. Recent consensus initiatives (SVS, AVF, SIR) have introduced the SVP classification (Symptoms–Varices–Pathophysiology) to provide clearer and standardised definitions.

Within the SVP framework, reflux-driven pelvic varices are designated V2P-R (presence of pelvic varices due to reflux). This pattern reflects intrinsic valvular insufficiency of the ovarian and/or uterine venous plexus and has frequently been described as pelvic congestion syndrome. Patients with this phenotype typically present with gynaecological symptoms and management commonly involves embolisation of refluxing ovarian or internal iliac tributaries.

This Delphi process focuses exclusively on this reflux-dominant ovarian/uterine insufficiency phenotype (SVP: V2P-R).

The objective of this Delphi study is to establish multidisciplinary consensus on terminology, symptom definitions, (imaging) diagnostic criteria and key exclusion diagnoses for V2P-R PeVD, aligned where appropriate with the SVP classification. Your expertise is essential in shaping a shared diagnostic framework that supports clearer communication and improved patient care.

1. What is your profession?(Required)

Gynaecology

Vascular Surgery

Interventional Radiology

Diagnostic Radiology

Phlebology

Other (specify):

Please describe your profession:

2. In which country do you work?(Required)

3. How many years of clinical experience do you have in PeVD?

None

5-10

11-20

>20

4. How many patients with (suspected) PeVD do you see per year (new or follow-up cases)?(Required)

None

1–10 patients

10–19 patients

20–30 patients

More than 30 patients

5. What is your main professional setting?

Academic / University

Tertiary Referral Center

Community Hospital

Private Practice

Other (specify):

5b. Please describe your professional setting?

6. Have you contributed scientific work related to PeVD, pelvic congestion syndrome (PCS) or chronic pelvic pain (CPP)?(Required)

None

1–4 peer-reviewed publications or conference presentations

5–10 peer-reviewed publications or conference presentations

More than 10 peer-reviewed publications or conference presentations

7. What is your (inter)national association with guidelines, protocols of societies considering PeVD?(Required)

I have been been involved in the development of local, national or international guidelines or protocols related to PeVD

I hold a recognized educational or leadership role in a professional society related to venous or pelvic pathology

I am a member of a national or international association with a working group or special interest in PeVD

none of the above

7b. Please provide us with some details:

8. Do you recommend any other experts for this Delphi procedure?

please provide us with an email address as well

9. Would you like to participate as a co-author?(Required)

Yes

If there are too many authors, contributors may be listed collectively as a research group, depending on the journal requirements.

Thank you for your effort, but you do not comply with our definition of an expert. We thank you for your time, but you cannot participate in this study. If any of the above statements apply to you, please continue to the next section.

Section A. Nomenclature

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

A1a. - Because experts use multiple terms (e.g. “pelvic congestion syndrome” and “Pelvic venous disorder type V2P-R”), we aim to create consensus on the name first. Which terminology best and most clearly designates the ovarian and uterine/parametrial plexus reflux–insufficiency phenotype

Ovarian/uterine plexus reflux–insufficiency

Pelvic venous insufficiency

Pelvic congestion syndrome

Ovarian vein reflux syndrome

Other

If "Other" is selected, please specify.

A1b. - Please briefly explain your choice, or if your checked other, please explain:

For the rest of this Delphi round, we will use the term PeVD V2P-R. This might change in the next round, depending on the consensus.

Section B. Chronic pelvic pain (CPP)

The European Association of Urology (EAU) defines Chronic Pelvic Pain 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 Chronic Pelvic Pain as pain perceived in the pelvic region for at least 6 months (7). According to Khan et al. (StatPearls, 2024), Chronic Pelvic Pain is typically established following 3–6 months of persistent pelvic pain (8).

B1a. - For defining chronic pelvic pain in the context of PeVD V2P-R, what should be considered the minimum duration of daily pain to call it Chronic Pelvic Pain?

≥ 3 months

≥ 6 months

Other

If "Other" is selected, please specify.

B1b. - Please briefly explain your choice, or if you selected other, please provide us with an alternative:

B2a. - For defining chronic pelvic pain in the context of PeVD V2P-R, and when the pain is not daily, what should be considered the minimum number of days per month of pain to call it Chronic Pelvic Pain?

Present on ≥ 50% of days

Present nearly every day (> 80% of the time)

Present on at least 1 day per month

Other

If "Other" is selected, please specify.

B2b. - Please briefly explain your choice, or if you selected other, please provide us with an alternative:

B3a. - For the purpose of defining chronic pelvic pain in the context of PeVD V2P-R, when the pain is not daily, what should be considered the minimum duration of not daily pain to call it Chronic Pelvic Pain?

≥ 3 months

≥ 6 months

Other

If "Other" is selected, please specify.

B3b. Please briefly explain your choice, or if you selected other, please provide us with an alternative:

B4a. - In the context of PeVD V2P-R, at what point should dysmenorrhea (pain only during menstrual blood loss) be considered chronic pelvic pain? (e.g. if a women has 30 days of pelvic pain per month, but 7 of those she is also bleeding, does she have 30 days of Chronic Pelvic Pain, or 7 days dysmenorrhea and 23 days Chronic Pelvic Pain?)

Never, dysmenorrhea is not Chronic Pelvic Pain, but a different symptom (so 23 in the example above)

Women can differentiate between chronic pelvic pain and dysmenorrhea themselves. You can ask them if the pain during their period the same as the Chronic Pelvic Pain or different. If she describes a different pain, then these days are dysmenorrhea and should not be part of the Chronic Pelvic Pain.

When pelvic pain persists longer than 7 days (max duration of a normal menstruation) regardless of blood loss, then all the days are Chronic Pelvic Pain

When there is Chronic Pelvic Pain when a woman is not bleeding, you should add the days of dysmenorrhea as part of the days of chronic pain.

Other

If "Other" is selected, please specify.

B4b. Please briefly explain your choice, or if you selected other, please provide us with an alternative:

B5a. - The IASP definition requires that pain causes functional disability (7). Should functional interference (e.g. work, activities of daily living or sexual function) always be a required element of the Chronic Pelvic Pain definition?

Yes

B5b. Please briefly explain your choice, or if you selected other, please provide us with an alternative:

Based on our literature search and focus groups, we have collected a list of symptoms associated with PeVD V2P-R. Some are very typical, some are very general. We would like you to provide your assessment of each symptom. Please tell us how typically you find the following symptoms to be related to PeVD V2P-R?

	Not associated at all	Not typical	Mildly typical	Moderately typical	Highly typical	No opinion / not my expertise
Chronic pelvic pain (as defined above) unrelated to an acute pathology
Low-back pain unrelated to an acute pathology
Pelvic heaviness or pain worsening withstanding or at the end of the day
Pelvic pain worsening with sitting
Pain relief in the laying position or after leg elevation
Exertional leg pain or heaviness improving with rest
Unilateral/bilateral lower extremity edema
Nocturnal leg cramps
Dysmenorrhea not accompanied by heavy or irregular menses
Pain exacerbation before the menstruation/blood loss
Pain exacerbation after the menstruation/blood loss
Deep dyspareunia
Post-coital pelvic pain
Post-orgasmic pelvic pain
Pain or pressure in buttocks, perineum or posterior thigh after prolonged sitting/standing
Pain exacerbation after pregnancy
Pain exacerbation during pregnancy
Urinary frequency or urgency complaints without infection
Dysuria or suprapubic discomfort without infection
Bloating, constipation or diarrhea associated with pelvic pain
Flank pain
Localized pain in the iliac fossa, radiating anteriorly to the groin and medially to the proximal thigh
Hip pain
Nausea during pain flares
Vomiting during pain flares
Malaise during pain flares
Fatigue related to chronic pelvic pain
Lethargy related to chronic pelvic pain
Mood disturbance or emotional stress related to chronic pelvic pain
Sleep disruption or insomnia related to pelvic pain
Cognitive fatigue or concentration difficulty
Pain interference with daily physical or social activities
Pain during cycling
Rectal discomfort
Vulvar or perineal discomfort without visible varices
Pelvic pain worsening after ≥20–30 min standing
Deep perineal ache (suggestive of internal pudendal involvement)
Gluteal/piriformis-like ache

Do you have any additional comments or other related symptoms that we have missed?

For each physical finding listed below, please indicate if you find the following physical findings to be supportive of essential for the diagnosis of PeVD V2P-R:

	Not supportive nor essential finding	Only supportive finding	Essential finding	No opinion/outside of my expertise
Visible vulvar or perineal varices identified on inspection in standing and supine positions
Posteromedial thigh, gluteal or sciatic-territory varices contiguous with known pelvic escape veins (internal pudendal, obturator or gluteal)
Provoked pain upon palpation of vulvar varices or the sciatic outlet region, consistent with venous origin
Lower-extremity varices extending from the perineal or gluteal region toward the posterior or medial thigh
Presence of cervical-motion tenderness on bimanual examination
Ovarian-point tenderness reproducing presenting pain on bimanual palpation
Pelvic or adnexal fullness/tenderness accentuated by Valsalva or upright posture
The absence of pelvic pain or tenderness during abdominal examination
Pain/tinnel sign during vaginal examination of the pudendal nerve/S4-S2
Increase in pain during transvaginal ultrasound examination of the para cervical and/or ovarian veins
Pelvic floor tone or tenderness grading (hypertonicity/dysfunction)

Do you have any additional comments or other physical findings that are relevant that we missed?

Chronic pelvic pain is a multifactorial disorder in which different factors frequently overlap (9). Before attributing symptoms to the ovarian/uterine reflux–insufficiency phenotype (PeVD V2P-R), structured assessment of key differential domains is required to exclude or contextualize alternative causes.

E1a. Based on your clinical and/or research experience, please indicate your expert opinion for each condition listed within the medical domains below:

A. Gynaecological Domain
Endometriosis and adenomyosis are the leading gynecologic causes of Chronic Pelvic Pain, accounting for up to 40 % of diagnostic laparoscopies (9). Chronic pelvic inflammatory disease and pelvic adhesions can produce overlapping venous-type pain and should be assessed before diagnosing PeVD V2P-R.

In your experience, how often do the following conditions coexist with PeVD V2P-R?

	unlikely	occasional	common	very common	No opinion/outside of my expertise
Endometriosis
Adenomyosis
Chronic pelvic inflammatory disease
Pelvic adhesions
Vulvo/vestibulodynia
Uterine fibroids
Adnexal masses
Cesarean scar disorder

Should you exclude any of the following conditions to diagnose PeVD V2P-R?

	Essential to exclude	Not essential to exclude	No opinion/outside of my expertise
Endometriosis
Adenomyosis
Chronic pelvic inflammatory disease
Pelvic adhesions
Vulvo/vestibulodynia
Uterine fibroids
Adnexal masses
Cesarean scar disorder

Do you have any additional comments?

B. Urologic Domain
Bladder pain syndrome (BPS) and recurrent urinary tract infection are key urologic causes of Chronic Pelvic Pain that may coexist with gynecologic or venous pain through shared neurogenic pathways (9,10). These disorders often mimic the dull suprapubic or perineal pain described in PeVD V2P-R.

In your experience, how often do the following conditions coexist with PeVD V2P-R?

	unlikely	occasional	common	very common	No opinion/outside of my expertise
Bladder pain syndrome/ interstitial cystitis
Recurrent urinary tract infection
Chronic renal/bladder stones

Should you exclude any of the following conditions to diagnose PeVD V2P-R?

	Essential to exclude	Not essential to exclude	No opinion/outside of my expertise
Bladder pain syndrome/ interstitial cystitis
Recurrent urinary tract infection
Chronic renal/bladder stones

Do you have any additional comments?

C. Gastrointestinal Domain
Functional bowel disorders such as irritable bowel syndrome (IBS) and chronic constipation affect up to 40 % of women with Chronic Pelvic Pain and share visceral hypersensitivity pathways with urologic and gynecologic pain (9).

In your experience, how often do the following conditions coexist with PeVD V2P-R?

	unlikely	occasional	common	very common	No opinion/outside of my expertise
Irritable bowel syndrome
Inflammatory bowel disease (Crohn’s/ulcerative colitis)
Chronic constipation
Chronic appendicitis

Should you exclude any of the following conditions to diagnose PeVD V2P-R?

	Essential to exclude	Not essential to excluse	No opinion/outside of my expertise
Irritable bowel syndrome
Inflammatory bowel disease (Crohn’s/ulcerative colitis)
Chronic constipation
Chronic appendicitis

Do you have any additional comments?

D. Musculoskeletal/Neuropathic Domain
Pelvic-floor myofascial pain, sacroiliac joint dysfunction, and abdominal-wall trigger-point pain are present in 20–90 % of Chronic Pelvic Pain patients (9). Neuropathic pain syndromes such as pudendal or ilioinguinal neuralgia may reproduce venous-type pain and warrant clinical evaluation.

In your experience, how often do the following conditions coexist with PeVD V2P-R?

	unlikely	occasional	common	very common	No opinion/outside of my expertise
Pelvic floor myofascial pain
Abdominal-wall trigger-point pain
Hip and lumbosacral disorders
Hernias
Ilioinguinal neuropathic pain
Pudendal neuropathy
Radiculopathy
Entrapment/neuromas
Fibromyalgia

Should you exclude any of the following conditions to diagnose PeVD V2P-R?

	Essential to exclude	Not essential to exclude	No opinion/outside of my expertise
Pelvic floor myofascial pain
Abdominal-wall trigger-point pain
Hip and lumbosacral disorders
Hernias
Ilioinguinal neuropathic pain
Pudendal neuropathy
Radiculopathy
Entrapment/neuromas
Fibromyalgia

Do you have any additional comments?

E. Vascular Domain
The aim in this domain is to identify vascular conditions that should be differentiated from, or recognized as potentially coexisting with, the ovarian/uterine reflux–insufficiency phenotype (PeVD V2P-R).

In your experience, how often do the following conditions coexist with PeVD V2P-R?

	unlikely	occasional	common	very common	No opinion/outside of my expertise
Left renal vein compression (Nutcracker)
Iliac vein compression (May–Thurner)
Post-thrombotic iliac or femoral obstruction/ residual deep vein thrombosis (DVT)
Internal iliac reflux phenotype (V2)
Phlebo-lymphedema
Pelvic lymphatic dysfunction

Should you exclude any of the following conditions to diagnose PeVD V2P-R?

	Essential to exclude	Not essential to exclude	No opinion/outside of my expertise
Left renal vein compression (Nutcracker)
Iliac vein compression (May–Thurner)
Post-thrombotic iliac or femoral obstruction/ residual deep vein thrombosis (DVT)
Internal iliac reflux phenotype (V2)
Phlebo-lymphedema
Pelvic lymphatic dysfunction

Do you have any additional comments?

E2a. Should the following medical history or previous treatments be considered when diagnosing PeVD V2P-R?

	Should be considered	Should NOT be considered	No opinion/outside of my expertise
History of deep-vein thrombosis (DVT) or post-thrombotic changes
Previous venous treatment (e.g. embolisation, compression therapy, stenting)
Results from previous imaging studies (e.g. duplex ultrasound, phlebography, computed tomography, magnetic resonance imaging.)

Do you have any additional comments?

F1a. Which of the following non-imaging diagnostic tests do you consider relevant for diagnosing PeVD V2P-R?

	Not relevant	Limited relevant	Moderately relevant	Relevant	Highly relevant test	No opinion/outside of my expertise
Detailed pelvic pain history (cyclicity, posture-dependence, post-coital or post-menstrual pattern)
Diagnostic laparoscopy
β-hCG test
Urinalysis and urine culture
Inflammatory markers (CRP, ESR, leukocyte count)
Hormonal laboratory testing (FSH, LH, estradiol, progesterone)
Menopausal status
Hormone replacement therapy use
Pelvic floor assessment (for example by digital palpation, manometry or EMG for myofascial dysfunction)
Symptom difference standing vs. supine
Symptom relief after leg elevation or rest

Do you have any additional comments or non-imaging tests that are relevant that we missed?

Which parameters of the Transabdominal Ultrasound (TAUS) do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Is TAUS (basic reflux screening) relevant for diagnosing reflux-dominant PeVD (V2P-R)?
Presence of retrograde caudal flow on duplex with Vasalva or spontaneously, ≥ 1s reflux may be used as a practical threshold.
Ovarian vein diameter of ≥ 5-6 mm suggests dilatation and > 8 mm suggests marked dilatation. Use only in conjunction with reflux or variceal findings.

Which parameters of the Transvaginal Ultrasound (TVUS) do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Is TVUS (high sensitivity for parametrial/uterine plexus reflux during Valsalva) relevant for diagnosing reflux-dominant PeVD (V2P-R)?
Color or spectral Doppler reflux in the parametrial/uterine plexus during Vasalva.
Presence of ≥ 4-6 mm peri-uterine or para-ovarian veins with slow flow ≤ 3 cm/s.
Presence of reflux or dilatation in paravesical veins adjacent to the bladder wall.
Increased anterior or posterior vaginal wall thickness.

Which parameters of the Pelvic venography (Selective Ovarian/ Internal Iliac) do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Is pelvic venography (gold standard before embolization, reflux grade, cross-filling, delayed clearance) relevant for diagnosing reflux-dominant PeVD (V2P-R)?
Qualitative delayed (> 20s) or stagnant contrast clearance.
Retrograde caudal flow with cross-filling or internal-iliac filling and vulvar/thigh variceal opacification.
Balloon occlusion test: temporary occlusion of the refluxing vein with symptom assessment or hemodynamic measurement.

Which parameters of the Magnetic Resonance Venography (MRV) do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Is MRV/TR-MRV (mapping of collateral pathways and assessment of delayed venous drainage) relevant for diagnosing reflux-dominant PeVD (V2P-R)?
Peri-uterine plexus varices and/or ovarian vein ≥ 8 mm with delayed venous drainage.
Time-resolved (TR) MRV to assess dynamic reflux/flow patterns.

Which parameters of the Intravascular Ultrasound (IVUS) do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Is IVUS (assessment of iliac/renal outflow obstruction severity) relevant for diagnosing reflux-dominant PeVD (V2P-R)?
≥50% area reduction with ≥ 61 % diameter.

Which parameters of the Computed Tomography Venography (CTV) do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Is CTV (for venous diameter mapping) relevant for diagnosing reflux-dominant PeVD (V2P-R)?
≥ 4 para-uterine veins with ≥ 1 > 4 mm and/or ovarian vein > 8 mm.

Which parameters of the Dynamic assessment during imaging do you find relevant?

	Relevant parameter	NOT relevant parameter	No opinion/outside of my expertise	Unavailable in my practice
Perform imaging dynamically (e.g., during Valsalva, real-time contrast injection or time-resolved MRV) to detect reflux. (applicable to ultrasound, phlebography and TR-MRV.)
For ultrasound, assess in semi-upright and supine positions, as reflux or venous distension may be posture-dependent.

Do you have any additional comments?

Which of the following statements do you agree with?

	Agree	Disagree	No opinion/outside of my expertise	Unavailable in my practice
Transvaginal and/or transabdominal duplex ultrasound should be used as first-line imaging, incorporating Valsalva and semi-upright positioning to assess reflux and vein dilatation.
MRV is the preferred second-line test when duplex is equivocal or mapping is needed.
CTV is acceptable if MR is unavailable.
Pelvic phlebography remains the gold standard when non-invasive imaging is inconclusive or treatment is planned, with reflux grade, cross-filling and qualitative contrast clearance documented.
IVUS or positional venography should be used when outflow obstruction (e.g., May–Thurner, Nutcracker) is suspected to define lesion significance and guide therapy.
Bilateral ovarian and/or uterine venous reflux increases diagnostic confidence in the assessment of PeVD V2P-R.
Imaging reports should specify vein diameters, reflux presence/duration, cross-filling, and patient position during acquisition. Imaging reports should document: vein diameters, presence/duration and direction of reflux, cross-filling pattern, and patient position during imaging acquisition.

Do you have any additional comments?