Pelvic venous disorders: a multidisciplinary Delphi consensus on nomenclature and diagnostic framework

Dear colleague,

Thank you for your valuable contribution to Round 1 of our Delphi study. We sincerely appreciate the time, expertise and input provided by this multidisciplinary expert panel.

You are now invited to complete Round 2.
In this round, you will be asked to re-rate the items that did not reach the predefined consensus threshold in Round 1, taking into account the way these items have been clarified or refined. You will also be asked to rate revised statements and new statements developed from the Round 1 comments.

Consensus remains predefined as ≥70% agreement. Items that do not reach consensus in Round 2 may be further refined and re-assessed in subsequent rounds (typically a total of 3–4 rounds, with a potential final digital focus group if needed).
Thank you again for your continued contribution.

In Round 1, the conditions listed below were evaluated for both their likelihood of coexisting with V2P-R and the necessity of excluding them before diagnosis. None reached consensus on mandatory exclusion. They are divided here into two groups based on their coexistence data:

• Group A: consensus was reached that coexistence with V2P-R is generally uncommon, but no consensus was reached on whether exclusion should be routine.
• Group B: no consensus was reached on either coexistence or exclusion.

Section F. Medical History

In Round 1, there was consensus that venous history items (History of deep-vein thrombosis, previous venous treatment and medical imaging) should all be recorded. These agreed items will not re-rated in Round 2.

In Round 2, we include follow-up statements to clarify how prior imaging, comorbidities and prior treatment response should be handled in the diagnostic framework.

Round 1 comments noted that prior and current venous imaging for V2P-R can differ due to technique/protocol, patient position and changes over time.

In Round 1, experts suggested that symptom improvement after embolisation or stenting may support a venous contribution to symptoms.

Section G. Non-imaging diagnostic tests

In Round 1, the experts rated the relevance of each non-imaging diagnostic test in the evaluation of suspected V2P-R using a relevance scale. For analysis, adjacent categories were merged: ‘’Relevant’’ (Highly relevant + Relevant) and ‘’Limited relevance’’ (Moderately relevant + Limited relevant) and ‘’Not relevant’’ remaining separate.

The following non-imaging diagnostic tests relevant in the evaluation of suspected V2P-R with consensus:

1. Detailed pelvic pain history (including cyclicity, posture-dependence, post-coital and post-menstrual features)
2. Symptom difference standing vs supine
3. Symptom relief with rest and/or leg elevation

Non-imaging tests that did not reach consensus in Round 1 will therefore be re-rated in Round 2 (see below). In addition, some new tests suggested by the experts in Round 1 have been added in Round 2.

Section H. Medical Imaging

Round 1 achieved consensus on imaging parameters and diagnostic thresholds across multiple modalities, as well as on the consensus statements on preferred imaging approach and diagnostic hierarchy in suspected V2P-R. These items are summarized below.

Imaging must always be interpreted in the context of the clinical presentation. Vein diameter alone is insufficient and findings are sensitive to acquisition protocol and patient positioning. A workflow-focused imaging pathway incorporating these principles will be developed in Round 3 of this Delphi.

The following imaging parameters and diagnostic thresholds for V2P-R with consensus:

1. Transabdominal ultrasound (TAUS): First-line reflux screening tool. Key parameters: retrograde caudal flow ≥1 second on duplex (with Valsalva or spontaneously); ovarian vein diameter ≥5–6 mm (dilated) and >8 mm (markedly dilated), interpreted only alongside reflux or variceal findings.
2. Transvaginal ultrasound (TVUS): High-sensitivity modality for uterine/parametrial venous plexus. Key parameters: qualitative color Doppler flow reversal in the uterine/parametrial venous plexus during Valsalva, peri-uterine or para-ovarian veins ≥4–6 mm with slow flow ≤3 cm/s, reflux or dilatation in paravesical veins. Increased vaginal wall thickness reached consensus as not relevant.
3. Pelvic venography: Gold standard when non-invasive imaging is inconclusive or intervention is planned. Key parameters: delayed (>20 seconds) or stagnant contrast clearance; retrograde caudal flow with cross-filling, internal-iliac filling or vulvar/thigh variceal opacification.
4. MR venography (MRV/TR-MRV): Preferred for collateral pathway mapping. Key parameters: dilated uterine/parametrial venous plexus and/or ovarian vein ≥8 mm with delayed venous drainage; time-resolved MRV for dynamic reflux assessment.
5. Cross-modality requirements: Dynamic acquisition (Valsalva, real-time injection or TR-MRV) and assessment in both semi-upright and supine positions are required across all modalities.

The following statements on imaging approach and diagnostic hierarchy with consensus:

1. First-line imaging should be transvaginal and/or transabdominal duplex ultrasound, performed with Valsalva manoeuvre and postural assessment.
2. MRV is the preferred second-line modality when duplex findings are equivocal or anatomical mapping is required.
3. Computed tomography venography (CTV) is acceptable when MR is unavailable.
4. Selective venography remains the reference test when non-invasive imaging is inconclusive or intervention is planned, with reflux grade, cross-filling, and contrast retention documented.
5. IVUS or positional venography should be incorporated when outflow obstruction (Nutcracker phenomenon or May–Thurner syndrome) is suspected.
6. Bilateral ovarian and/or uterine venous reflux increases diagnostic confidence and clinical significance compared to unilateral reflux.
7. Imaging reports should document vein diameters, presence/duration and direction of reflux, cross-filling pattern, and patient position during acquisition.