
==== Front
Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00190-6
10.1016/j.eucr.2024.102836
102836
Functional Urology
Ovarian vein syndrome – Rare ovarian vein compression of the ureter
Chee Ryan K.W. rchee@ualberta.ca

Koshy Reshma M. rmarykos@ualberta.ca

Wilson Mitchell P. mitch.wilson@ualberta.ca

Low Gavin low1@ualberta.ca
⁎
Department of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
⁎ Corresponding author. Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, WMC 2B2.41 8440-112 ST, Edmonton, Alberta, T6G2B7, Canada. low1@ualberta.ca
28 8 2024
9 2024
28 8 2024
56 10283617 8 2024
21 8 2024
27 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Ovarian vein syndrome is a rare condition involving the compression of the ureter by the ovarian vein. Since it was first described, very few cases have been reported in literature. We present a case of a 37-year-old female with typical symptoms and common right-side involvement. The imaging findings on ultrasound, CT, and nuclear medicine imaging are classic for her condition.

Keywords

Ovarian vein syndrome
Vascular compression of the ureter
Vascular compression syndromes
==== Body
pmc1 Introduction

Ovarian vein syndrome (OVS) is a rare condition caused by external compression of the ureter by a dilated ovarian vein resulting in ipsilateral hydroureter and hydronephrosis. OVS is characterized by nonspecific findings such as abdominal/lower back pain, recurrent urinary tract infections (UTIs), and urinary symptoms such as renal colic, hematuria, dysuria, urinary frequency, and urinary urgency.1,2 Ovarian vein syndrome was first described by Clark in 1964,1 but relatively few cases have been reported in literature since. Thus, the exact prevalence of OVS is unknown.

2 Case presentation

A 37-year-old female presented with macroscopic hematuria and dysuria. Urinalysis and urine culture showed no signs of a UTI. Initial ultrasound imaging of the abdomen and pelvis (Fig. 1) found mild hydronephrosis in the right kidney with good flow in the distal ureter on color doppler imaging. No structural abnormalities were identified on ultrasound to explain the patient's macroscopic hematuria.Fig. 1 Ultrasound of the abdomen and pelvis. (a) Sagittal image of the right kidney adjacent to the liver showing mild hydronephrosis. (b) Transverse image of the right kidney showing mild hydronephrosis. (c) and (d) Transverse color doppler image of the bladder showing good flow in the distal right ureter. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 1

Follow-up imaging was done using multiphasic CT of the abdomen and pelvis (Fig. 2). CT again found mild hydronephrosis in the right kidney. The ureteropelvic junction was dilated with compression from a dilated right ovarian vein crossing distally measuring 9 mm in diameter. There was no delayed nephrogram or cortical thinning to suggest any functional significance to this compression.Fig. 2 Multiphasic CT of the abdomen and pelvis. (a) Axial image showing mild hydronephrosis in the right kidney. (b) Sagittal image with white arrows pointing to the course of a dilated right ovarian vein as it crosses distal to the dilated ureteropelvic junction. (c) Axial image showing a dilated right ovarian vein measuring 9 mm in diameter. (d) Coronal nephrographic phase CT image showing mild right hydronephrosis.

Fig. 2

To assess functional impairment, diuretic scintigraphic renography (Fig. 3) was performed using Technetium (Tc)-99m mercaptoacetyltriglycine (MAG3) and furosemide administered 10 minutes prior to imaging. The renal scan showed normal and relatively symmetric renal perfusion. The split function measured 44 % on the left and 56 % on the right. The kidneys demonstrated normal bilateral emptying.Fig. 3 Diuretic scintigraphic renography using Tc-99m MAG3. (a) Coronal image showing normal flow into the kidneys bilaterally. (b) Coronal image showing no delay in drainage from the kidneys bilaterally. (c) A flow graph showing relatively similar initial flow into the kidneys. (d) A renogram graph showing prolonged filling of the right kidney followed by normal bilateral emptying of the kidneys.

Fig. 3

Finally, cystoscopy was performed to confirm the absence of an obstructing lesion. Given a normal renal perfusion scan and adequate investigation to rule out an obstructing lesion, there was no indication for intervention at the time.

3 Discussion

The pathophysiology of OVS is thought to be multifactorial resulting from a combination of ovarian vein dilation, connective tissue fixation, and hormonal changes. Ovarian vein dilation can be secondary to variant embryological development such as persistent posterior subcardinal veins and is also seen in pregnancy secondary to external compression by a gravid uterus.1,2 It is noted that while the ovarian veins may be dilated during pregnancy, there is a relatively small decrease in venous pressure.1,2 Thus, compression of the ureter is likely facilitated by additional connective tissue fixation of the ovarian vein to the ureter.1,2 Fluctuations in estrogen and progesterone levels in pregnancy are also thought to contribute to ureteric compression due to a decrease in tone of the ureteric wall.1,2 Progesterone increases the flow in the ovarian vein while estrogen causes relaxation of the smooth muscle in the ureter.

OVS is most commonly right-sided and often seen in multiparous women. The right ovarian vein drains directly into the inferior vena cava, so aberrant veins such as persistent embryologic vasculature are more likely to drain into the right ovarian vein resulting in dilation.1 While in pregnancy, there are physiologic changes that result in dilation of the ovarian vein and increased ureteric compressibility.

The initial imaging modality for OVS is ultrasound. Diagnostic features on ultrasound include a dilated ovarian vein ≥6 mm, hydroureter at the level of L3/4, and possible reversal of ovarian vein flow on color doppler.1 When ultrasound is inconclusive, CT or MRI is the next step with diagnostic clues including dilation of the ovarian vein ≥8 mm and ipsilateral hydroureter.1

Treatment can be explored in cases of significant symptoms or functional impairment. Medical treatment of ovarian vein syndrome include medoxyprogesterone acetate or goserelin acetate which cause venous contraction.1 If refractory to medical management, interventional radiologic therapies such as coil embolization and sclerotherapy can be used to embolize the ovarian vein 1. Finally, surgical ovarian vein ligation is another effective option. Several case reports of surgical treatment of OVS can be seen in literature.3,4,5,6

4 Conclusion

Cases of ovarian vein syndrome are uncommonly presented in literature. Patients often present with non-specific findings of pain and urinary symptoms. We present a case of right ovarian vein syndrome with typical symptomatology and imaging findings.

Patient consent declaration

Patient consent was not required as the patient's identity was no compromised in this case report.

Funding source declaration

The authors have no funding sources to declare.

CRediT authorship contribution statement

Ryan K.W. Chee: Writing – review & editing, Writing – original draft, Visualization, Validation, Investigation, Formal analysis, Data curation, Conceptualization. Reshma M. Koshy: Writing – review & editing, Visualization, Investigation, Data curation. Mitchell P. Wilson: Writing – review & editing, Supervision, Project administration. Gavin Low: Writing – review & editing, Supervision, Conceptualization.

Declaration of competing inerest

The authors have no conflicts of interest to declare.
==== Refs
References

1 Bhutta H.Y. Walsh S.R. Tang T.Y. Walsh C.A. Clarke J.M. Ovarian vein syndrome: a review Int J Surg 7 6 2009 Nov 1 516 520 19818884
2 Wang R. Yan Y. Zhan S. Diagnosis of ovarian vein syndrome (OVS) by computed tomography (CT) imaging: a retrospective study of 11 cases Medicine 93 7 2014 Aug 1 e53
3 Gettman M.T. Lotan Y. Cadeddu J. Laparoscopic treatment of ovarian vein syndrome J Soc Laparoendosc Surg: J Soc Laparoendosc Surg 7 3 2003 Jul 257
4 Almeida A. Cavalcanti F. Barbosa S. Cohen R. Medeiros A. Laparoscopic approach in the ovarian vein syndrome Int Braz J Urol 29 2003 45 47 15745468
5 Manoharan V. Parmar K. Mavuduru R.S. Rai T. Tyagi S. A rare indication of robot-assisted uretero-ureterostomy: ovarian vein syndrome J Robotic Surg 13 2019 Oct 703 705
6 Hmida W. Othmen M.B. Mallat F. Chavey S.O. Jaidane M. Mosbah F. Laparoscopic treatment of ovarian vein syndrome: a case series Int J Case Rep Images 5 11 2014 Nov 1 739 743
