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Background: Pelvic congestion syndrome (PCS) imaging workup algorithms are not well-defined. The purpose of our study is to gauge the impact and accuracy of duplex ultrasound (DU) to assist in the diagnosis of PCS., Methods: We reviewed the records of 48 patients with PCS seen at a vein center from June 2010 to June 2012. All patients had DU plus either computed tomography venography (CTV) or conventional venography (CV). Measurements of the left (LOV) and right ovarian vein (ROV) diameter and the presence or absence of ovarian vein reflux were obtained using DU and compared with either CTV or CV to assess sensitivity and specificity. An ovarian vein diameter >6 mm was considered abnormal., Results: All patients were female (29 Caucasians, 18 Hispanic, and 1 Asian). The mean number of pregnancies was 3 (range, 1-5). All patients had lower extremity varicose veins, and 14 (29%) had vulvar varicosities. Thirty-four (71%) patients reported pelvic pain, 22 (46%) dyspareunia, 2 (4%) dysuria, and 1 (2%) hematuria. The median diameter of the LOVs and ROVs measured using DU compared with either CTV/CV were similar (DU, 8.6 and 5.6; CTV/CV, 8.3 and 6). The sensitivity and specificity of DU to demonstrate a dilated LOV were 100% and 57%, and for the ROV were 67% and 90%. Pelvic varicosities were identified in all but one patient with good correlation between DU and CV., Conclusions: DU has a high sensitivity to identify an abnormal LOV diameter that is greatly reduced when evaluating the ROV; however, the latter can be evaluated with another imaging modality such as CTV especially when DU results are equivocal or negative. A moderate specificity was found to determine both LOV and ROV abnormal diameters. All three imaging modalities are equally accurate to show the presence of pelvic varices., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)