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dr Cezary Szary

Pelvic venous insufficiency and related varicose veins in vulvoperineal region are the most underdiagnosed or even neglected problem in modern phlebology and gynecology .
 

Knowledge on the occurrence of unsightly widened veins in intimate area (i.e. perineal and vulvar varicose veins) is relatively poorly disseminated, both in physicians and patients. For a number of years, this problem was underestimated and neglected by physicians. As it turns out, varicose veins in intimate area are present even in one out of ten pregnant women and its presence increases with the successive labours. Most frequently, females who delivered the second or third child visit gynaecologists.  

In the majority of our cases, subcutaneous dilatation of veins present in the area of vulva, perineum, buttocks and upper part of thighs have a direct relation with pelvic venous insufficiency (PVI). Occurrence of varicose veins in this area in females is frequently associated with a syndrome of very discomforting symptoms referred to as pelvic congestion syndrome (PCS). Such condition was first noticed a number years ago by Richet (1857) and Aran (1858). The real definition of pelvic congestion syndrome was formulated nearly 100 years later by Taylor (1949).  

The notion of this syndrome comes from an excess of venous blood, which is collected in widened pelvic venous plexus, near ovaries, uterus, parametrium and via descendant way to vagina. There are various types of configuration of such varicose veins, including varicose veins on legs with atypical appearance. Varicose veins on legs which result from pelvic venous insufficiency are professionally referred to as  atypical varicose veins. Usually, they appear on the anterior or anterior/posterior part of thighs. Sometimes, they begin on the buttocks or the area of vulva and come downside.

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Are pelvic venous insufficiency and varicose veins in intimate area a prevalent social problem?

Our every day practice suggests that it is a prevalent disorder. It is mainly diagnosed in females after the delivery, especially the second or third one. This problem is more frequently observed following multiple pregnancies, including females who were subject to long hormonal therapy, e.g. in vitro fertilization. 

Females who visit the Clinic of Phlebology are typically aged 25-45. In this period, the symptoms of pelvic congestion syndrome and cosmetic defect resulting from the presence of varicose veins in intimate area are mostly expressed. According to the studies conducted nearly 20 years ago on a group of females delivering children at the age of 18 and 50 years, even 15% of females would experience chronic pain in pelvis. It is estimated that even up to 30% of patients with chronic pain in lower parts of abdomen suffer from pelvic venous insufficiency. Moreover, it turns out that in case of 10-15% of females who have varicose veins on legs, their starting point is at the level of abnormally functioning veins in pelvis.

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What are the reasons of varicose veins in intimate area and symptoms of pelvic venous insufficiency?

Current observations allow for assuming that the appearance of varicose veins in pelvis is mostly associated with abnormal configurations of veins in abdominal cavity, congenital susceptibility of ovarian veins to stretch (typically, it is observed in pregnancy) and congenital weakness or the lack of valves in their lumen. Each successive pregnancy is a greater challenge for veins. During pregnancy, we observe even 50-fold increase in the blood flow within ovarian veins, which results in their overburdening and excessive widening. Other factors that favour the disease are various kinds of compression syndromes, abnormal position of uterus or history of vein thrombosis in pregnancy or perinatal period.

What are the symptoms of pelvic venous insufficiency?

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Depending on the form of disease and patient’s resistance to pain, symptoms experience by patient may vary and they are of different intensity. Varicose veins, which appeared during first or second pregnancy within the area of vulva and perineum should be the first signal suggesting a potential problem. If such lesions are accompanied by dilatation of small vessels on legs during pregnancy (typically spider veins on posterior  surfaces of thighs) and varicose veins descending to shin, it is worth to interest in this subject 3-6 months following the delivery.  

If patients, following the deliveries, suffer from constant heaviness, discomfort or pain in lower parts of abdomen which is hardly to describe and which is not associated with eating, but sitting or standing for a long time, most frequently have a more severe form of the disease. In a number of females, pelvic congestion syndrome results in pain and burning sensation during sexual intercourse or just following it. Burning sensation and distention in the intimate area may persist even for up to 2-3 days following sexual intercourse. A list of typical symptoms also includes heavy menstrual bleeding, tension pain in ovarian region and polyuria. Patients frequently report heavy pain during transvaginal ultrasound (TV-ultrasound) performed by gynaecologist. These are symptoms, which analyzed separately, are frequently neglected by physicians.  

How is pelvic venous insufficiency diagnosed currently?

A right diagnosis is made by excluding other diseases that may imitate the symptoms of pelvic venous insufficiency and after determination of typical symptoms specified above. In the Clinic of Phlebology, each patient should fill in a special questionnaire which allows in a credible way for determining which of the reported ailments are the most important. Analysis of impaired veins and establishment of the source of returning blood is important for the treatment of pelvic venous insufficiency. It is not possible without a precise imaging diagnostics.

Thus, we always perform a required set of imaging examinations which are adjusted to a specific case.  Routinely, we begin diagnostic process from Doppler ultrasound of pelvic and abdominal venous system combined with evaluation of intimate area veins and venous sufficiency on lower extremities. For such examinations, patients need to fast, after adequate hydration on the day of examination (more information can be accessed in the section FREQUENTLY ASKED QUESTIONS).

In certain cases, phlebologist also orders examination of small pelvis via transvaginal ultrasound (TV-ultrasound) to exclude other, additional dysfunction in the region of reproductive organ.

Prior to making a decision and planning a potential procedure, more precise imaging examinations are made. In the team of the Phlebology Clinic, well-trained radiologists deal with that:

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Cezary Szary

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Michał Zawadzki

Depending on the needs, we perform a comprehensive range of imaging examinations of venous system, i.e.:

- classic phlebography using digital angiography *
- classic varicography (imaging of varicose veins following administration of contrast agent) *
- contrast venography using computed tomography (CTV) *
- contrast and non-contrast venography using magnetic resonance imaging (MRV)
- intravascular ultrasound (IVUS) *

Examinations marked with asterisk (*) are performed by our radiologists in the Medicover Hospital in Warsaw (Wilanów). MRI venography (MRV) are performed onsite in collaboration with the Sports Medicine Center in Warsaw (Wawelska 5). For such purpose, modern high-field magnetic resonance by Philips (the power of magnetic field equal to 3 Teslas) is used. Besides imaging of the venous system via MRI, it allows for diagnosing the most common diseases which imitate the symptoms of pelvic congestion syndrome such as endometriosis, adenomyosis of uterus, inflammation of small pelvis organs and enteritis.

How the treatment of pelvic venous insufficiency looks like? Who deals with the treatment of such condition?

In the Clinic of Phlebolgy, the team composed of specialists representing the following fields: phlebology, imaging diagnostics and interventional radiology deals with the diagnostics and treatment of pelvic venous insufficiency. In more severe cases, we also collaborate with gynaecologists and vascular surgeons who know precisely this subject.  

Therapeutic approach is dependent on the aetiology of disease. The greatest mistake consists in the treatment of varicose veins in intimate area without a precise diagnostic imaging. In our practice, we frequently meet cases in which the patient has undergone sclerotherapy of perineal varicose veins without a precise determining the aetiology of disease.  

In the most severe cases, in which pelvic venous insufficiency is accompanied by varicose veins in intimate area and legs, we apply a comprehensive approach. It consists in eliminating the reason of venostasis in small pelvis (via venous embolization, implantation of venous stent or chemical obliteration), and then treating varicose veins in the region of perineum, vulva and unsightly venous dilatations on legs (spider veins, dilated venulectasias and varicose veins).

In the hemodynamic unit of the Medicover Hopital, we definitely use mainly minimally invasive procedures performed intravascularly. Each procedure is performed under the guidance of ultrasound and digital angiographic devices (venogram is created). Venous embolization is performed during 4-6 hours admission to hospital, usually without a need to administer general anaesthesia, with shallow sedation.  Patient is conscious and reacts to the indications of physicians during the procedure.  

Atypical varicose veins and spider veins visible on legs, which appear as a result of pelvic venous insufficiency, are usually eliminated secondly. For such purpose, in the Clinic of Phleobology we use the most recent methods of minimal invasiveness for the patient (under local anaesthesia, usually without any incisions) such as:

- microsclerotherapy with liquid or foam
- various types of injection echosclerotherapy
- catheter-based mechanical and chemical obliteration using PHLEBOGRIFFE

- intravascular laser therapy under local anaesthesia (ELVeS 1470 nm)
- glue treatment of varicose veins of lower extremities using VariClose and VenaSeal
- miniphlebectomy and classic surgeries performed in one day

Information to remember:

  • varicose veins in intimate area appear mainly in females who deliver children, especially after 2-3 deliveries
  • symptomatic pelvic venous insufficiency (pelvic congestion syndrome) affects females at reproductive age, mainly those aged 25-45years
  • pelvic congestion syndrome is a disease which is often undiagnosed or misdiagnosed as endometriosis  
  • varicose veins, which are noticed by patient, usually appear in the region of labia, perineum, under buttock and upper parts of thighs

Our services

In the Phlebology Clinic offer you will find a full panel of venous and arterial imaging methods and the newest treatment methods of venous disorders in the whole body.