American College of Radiology

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October 16, 2017

Don’t make the diagnosis of Pelvic Congestion Syndrome on CT or MRI unless the patients meet clinical and imaging criteria.

Dilated pelvic veins can be an incidental, clinically insignificant finding on CT and MRI, or may reflect pelvic congestion syndrome. In the latter condition, dilated pelvic veins and venous reflux account for a range of symptoms, including chronic pain of more than 6-month duration. Radiologists must be cognizant of established criteria to suggest this diagnosis on CT and MRI. The diagnostic criteria include the following: 4 or more ipsilateral pelvic varicosities, 1 or more pelvic varicosities measuring more than 4 mm, ovarian (gonadal) vein dilatation > 8 mm in diameter.

In patients with dilated pelvic veins that do not meet these criteria, interpretations should not suggest Pelvic Congestion Syndrome. Furthermore, since these criteria were proposed by Coakley et al in 1999, several investigations have confirmed that ovarian vein reflux, ovarian vein dilatation and parauterine vein dilatation can be observed in asymptomatic patients, particularly multiparous women. Interpretations should recommend that clinical symptoms guide decision-making with respect to the need for vascular interventional consultation.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1-5) The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. Members of the group included the physician chairs or vice chairs of seven ACR commissions such as Quality and Safety, Appropriateness Criteria and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list.

(6-10) The Choosing Wisely initiative was presented to the organization’s physician leaders at a Board of Chancellors meeting and a working group selected five initial low-value imaging targets for reduced utilization. The second set of targets was created by the following working group, with the goals of minimizing unnecessary imaging and biopsy generated by discovery of incidental findings, improving patient safety through reduced radiation exposure, and reducing unnecessary consultations based on imaging findings.

  • Pamela T. Johnson, MD, Chair, Choosing Wisely Recommendations
  • Jacqueline A. Bello, MD, FACR, Chair of Commission on Quality and Safety
  • Mythreyi B. Chatfield, PhD, Executive Vice President for Quality and Safety
  • Jonathan Flug, MD, MBA, Quality Management Committee
  • Jenny K. Hoang, MBBS, lead author on ACR White Paper for Managing Incidental Thyroid Nodules
  • Alec J. Megibow, MD, MPH, FACR, Committee on Economics – Body Imaging Commission
  • Pari V. Pandharipande, MD, MPH, Chair of Committee on Incidental Findings
  • Saurabh Rohatgi, MD, Committee on Quality Experience – Commission on Patient and Family Centered Care

Research: For the topics related to incidental findings on imaging exams, the American College of Radiology has created evidence-based white papers to provide guidance to practicing radiologists on making management recommendations. The white paper publications and additional relevant literature serve as the evidence supporting those recommendations. For the remaining recommendations pertaining to body CT protocol design, published literature was reviewed to define acceptable indications for multiphase protocols.

ACR’s disclosure and conflict of interest policy can be found at


Coakley FV, Varghese SL, Hricak H. CT and MRI of pelvic varices in women. J Comput Assist Tomogr. 1999 May-Jun;23(3):429-34. PubMed PMID: 10348450.

Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES Jr. Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. AJR Am J Roentgenol. 2001 Jan;176(1):119-22. PubMed PMID: 11133549.

Hiromura T, Nishioka T, Nishioka S, Ikeda H, Tomita K. Reflux in the left ovarian vein: analysis of MDCT findings in asymptomatic women. AJR Am J Roentgenol. 2004 Nov;183(5):1411-5. PubMed PMID: 15505313.

Khosa F, Krinsky G, Macari M, Yucel EK, Berland LL. Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: white paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol. 2013 Oct;10(10):789-94. doi: 10.1016/j.jacr.2013.05.021. PubMed PMID: 24091049.