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So I'm going to talk a little bit about transvaginal duplex scanning for pelvic venous incompetencies and my name is Jia by the way, I'm from Singapore. So pelvic venous insufficiency or pelvic congestion syndrome, it's actually a painful condition that affects a lot of multiple female and most patients present with chronic pelvic pain, so pain in the pelvic area or draggy pain in the pelvic for more than six months and it counts for about 10 to 40 percent of gynecological referrals, which is quite a lot. But unfortunately it's under diagnosed at the moment because it's not well understood. So it's commonly missed because the symptoms are quite general and non-specific and can be similar to symptoms that you get from endometriosis, uterine prolapse, malignancies, adenomyosis or even thyroids. So often patients that present with chronic pelvic pain are referred to gynaecologists and then they do investigation more for assessment of mass or any other reasons but pelvic syndrome is the last thing they think of. So some of the symptoms that can present in patients with pelvic congestion syndrome are pelvic heaviness, lumbar pain sometimes, irritable bowel, irritable bladder and also heavy period and painful intercourse as well. So the reason why they can get irritable bowel, irritable bladder syndromes is because the varicose veins around the uterus can push on the rectum and the bladder and cause pain and issues there. And some other signs that you can see are vulvar varices because of that pressure pushing down to the leg, varices in the peroneal, gluteal or even the lower limbs as well. But, you know, a lot of patients can go asymptomatic too. So that's just a diagram to show that, you know, pressure or pelvic congestion in the pelvic area can lead to reflux down into the leg as well. Okay, so there are a few causes that can lead to pelvic congestion syndrome. Some mechanical, some hormonal, but it's quite common to see after pregnancy due to the increased blood flow to the pelvic area, causing dilation of the vein and hence resulting in pelvic vein incompetencies. Secondary causes of PCS can also be caused by external obstruction, so you You can get compression in the iodic veins, or venal vein traveling behind the aorta and getting compressed, called Knapp-Prekker syndrome. So why do we do transvaginal duplex ultrasound for diagnosis? Because it's much cheaper, more accessible, and there's no radiation involved. And with transvaginal ultrasound, we can assess, not only assess the vessels and the function of the vessels around the pelvic area in the innaxial area, but also rule out other potential causes of pelvic pain, such as what was mentioned before, fibroids, endometriosis, or any adhesions as well. And also while we are there, we can also assess if the vessels are affecting the bladder and the rectum. So what we normally get patients to do is to fast for six hours, and that's to clear out the bowel, because we don't really, ultrasound doesn't work very well with bowel. guess we'll obscure the structures so by fasting we'll get a much clearer picture of the structures. So we normally get to get to do the ultrasound scan we have the patient lying flat on the table and legs and knees apart and normally this is done straight after a patient empties their bladder so it's more comfortable for them and we do the scan with patient lying flat supine and with 15 degrees elevation of the bed as well to encourage gravity flow. So we look at the venous structures in pigment and colour, colour Doppler, and during the scan patient will be told to do valsalva manoeuvre as well. So some of the pelvic, the diagnostic criteria for pelvic venous incompetencies that we use, we look for pelvic varices, so veins in the annexal area or internal islet vein varices that are greater than six millimeters and they often have slow flow, lower than three centimeters per second, and dilated arcuate vein, crossing myometry and connecting both right and left. So I've got a few videos on how we do the scan. So these are normal cases that I've got here. So we sweep through the pelvic area in satchel like a normal pelvic transvaginal scan. So we're assessing B-rate first, looking at the vessel structures next to the uterus out here. So you can see that the vessels, the veins are quite normal in size, quite small. These are all normal. And then we'll We'll move on to do a transverse scan of both annexa. So this is a transverse view of the right annexa. I've got the venous plexus there, ovary here with a cyst, uterus on that side, and you can see that on this one, the venous diameter are quite small as well. So this is a color doppler function on the right annexa with valsalva maneuver. So you can see, so colour filling of the venous structure, this is arterial flow here and I can see colour filling all the veins with balsalma maneuver. And we do the same on the left side, so arterial flow, this one you're not seeing a lot of free flux here which is good. So these are all arterial but the veins are normal on that side. Okay so from there we move our camera out away from the cervix and we assess the vagina canal and sagittal. So that's the vagina canal there and you can look, we use this view to assess the vessels around the vagina canal and that's the rectum there and you can see that these are normal in size as well, definitely less than six millimetres. So these are arterial flow, so not really looking at that. Okay and then we'll move up, move in slightly. So this one we're looking around the bladder and the rectum, so that's the bladder sitting anteriorly. So see if there's any vessels around the bladder that's pushing on it or any varicoceles around the rectum as well. Okay, so here are some abnormal, well, positive pelvic congestion syndrome pictures. So you can see this is a transverse view of the left anexa with extremely dilated veins and a lot of tortuous veins surrounding there as well. And this one's measuring nine millimetres, so way over the six millimetres criteria. And you can see there's a lot of reflux color Doppler with Bulcella maneuver and on the same patient on the right side again dilated vein 6.9 millimeters and again reflux in color Doppler on that side and connecting both sides are the arcuate prophyseals and that's just a marina sitting in there.