Description of the condition

Varicose veins in the intimate areas in women represent pathological dilations of the venous vessels in the region of the external genitalia, inguinal canals, and the gluteal area. Their continuation and descent through continuity onto the lower limbs are frequently observed (usually in the medial-posterior or posterior thigh region). Varicose veins of the intimate areas are located within a much smaller space compared to varicose veins of the lower limbs. They are characterized by increased tortuosity, an increased diameter of the venous vessels, and a typical multi-layered arrangement. Their occurrence is dependent on significant gravitational forces, which are present during pregnancy or in cases of previous proximal cavo-iliac or ilio-femoral thromboses.

At Phlebology Clinic a division of varicose veins of the intimate area is used, based on their location and mechanism of formation. Of the total pool, the most common varicose veins located in the intimate area are:

• vulvar and perineal varicose veins (by far the most common type)
• varicose veins of the inguinal canals
• varicose veins of the gluteal and subgluteal regions

Each of these locations may have slightly different symptomatology and require a differentiated therapeutic approach. Very often varicose veins of the intimate area occur in complex systems. This is the case in multiparous women with multiaxial insufficiency of the ovarian veins and branches of the internal iliac veins. Such patients require a thorough diagnostic approach and treatment of all vascular axes and sinks, rather than embolisation of one side. Such a simplistic therapeutic approach - haemodynamically incomplete - often results in progression of venous disease in a symptomatic sense and makes it difficult to close or, less commonly, remove varicose veins of the intimate area.

Diagnosis and recognition of varicose veins of the intimate area

Diagnosis of varicose veins of the pelvic intimate area is based on a comprehensive clinical assessment and the use of Doppler ultrasonography and advanced imaging studies, such as magnetic resonance venography (MRV). The clinical part focuses on taking a full medical history of symptoms, including 'varicose veins', Patients who are more aware usually notice the problem of varicose veins of the intimate area themselves during pregnancy. They appear as early as the 24th week of pregnancy and become larger and larger until the pregnancy is terminated. Varicose veins of the intimate area are often accompanied by atypical varicose veins of the lower limbswhich do not fill directly from the main limb trunks, but from the vulva, perineum or inguinal canal.

Doppler ultrasonography

Doppler ultrasound is a non-invasive test, widely available and, compared to the MR venography relatively inexpensive. The biggest advantage of the ultrasound examination is that it can be performed under almost any conditions. The most important in the assessment of varicose veins of the intimate area is the standing position. It is this that reveals the important points of venous leakage and shows us the relevance of these sites and the resulting varicose veins to venous overload and insufficiency in the lower limbs. None of the other examinations (including transvaginal examination) can adequately investigate this quickly and minimally invasively. Ultrasound diagnosis of varicose veins of the intimate area is really a slice of the assessment of a patient with suspected pelvic venous insufficiency or obstructive (usually post-thrombotic) pelvic venous disease. Doppler venous ultrasound examinations with holistic assessment of the abdominal, pelvic and pelvic floor veins and the perineum require adequate training and experience of the doctor, also in terms of the ability to assess endometrial and postoperative changes.

Magnetic resonance venography (MRV)

MR venography (Magnetic Resonance Venography, MRV) plays a key role in accurately mapping varicose veins of the intimate area and determining the cause of their formation. It provides an advanced method of imaging the entire pelvic and abdominal venous system. Unlike classic X-ray phlebography, MR venography is non-invasive and allows a multifaceted assessment of the vessels along with their tissue and organ surroundings. This examination allows accurate visualisation of the anatomy of the veins of the pelvic floor, pelvis, including the iliac veins, ovarian veins and the entire vascular network of the peripheral circulation. Particularly important is the ability to accurately image venous stasis, which is of fundamental importance in the diagnosis of varicose veins of the intimate area. The diagnostic value of MR venography is particularly high when planning interventional procedures, as it provides the phlebologist or interventional radiologist with a precise anatomical map of the venous system.

In addition, MR venography allows the detection of possible developmental anomalies of the venous system, the exclusion of clinically relevant endometriosis and the assessment of the condition of the surrounding pelvic organs, which can be important in the treatment planning process. An undeniable advantage of MR venography is also the ability to perform the examination in different projections and using different sequences, which increases the likelihood of detecting even subtle abnormalities in the venous system. It is undoubtedly a technically difficult examination, requiring good equipment (preferably a 3-Tesla system) and due cooperation from the patient. The analysis of venographic studies requires a great deal of clinical experience on the part of the radiologist assessing these images and the ability to correlate MR findings with Doppler ultrasound of the pelvic and abdominal veins, which is essential in this type of assessment.

Computed tomography venography (CTV)

Computed tomography venography (Computed Tomography Venography, CTV) is an advanced diagnostic modality that is usually performed when MR venography is contraindicated in a patient with varicose veins of the intimate area. This specialised examination uses state-of-the-art imaging technology, combining X-rays with digital data processing to produce extremely accurate images of the venous system. A key element of the diagnostic process is the use of iodine contrast, which, when administered intravenously, significantly increases the visibility of blood vessels in the CT image.
The main advantages of CT venography in the diagnosis of varicose veins of the intimate area are: extremely short examination time (only 3 minutes), ability to create advanced 3D reconstructions of the vascular system, excellent spatial resolution, ability to detect anatomical anomalies and vascular pathologies, including venous pressure phenomena. As far as limitations are concerned, there is certainly a much lower tissue resolution compared to MR venography, the patient's exposure to ionising radiation and the need to administer an intravenous shadowing agent, which can cause allergic reactions. A major disadvantage un Patients of reproductive age is the limited effectiveness in detecting endometrial lesions.

Treatment of varicose veins of the intimate area

The treatment of varicose veins of the intimate area begins in most cases with the search for the cause and the formation and treatment of this cause. The most common strategic mistake is to treat varicose veins of the intimate area symptomatically, without excluding venous congestion in the reservoir venous vessels of the small pelvis. The laws of fluid physics (blood is one of them too) are the same everywhere in nature and where gravity acts on us.

Appropriate treatment venous pelvic disease is usually the first stage in the treatment of varicose veins of the intimate area. It is the so-called. sequential treatment (staged), carried out descendingo, i.e. from top to bottom. For decades, venous insufficiency of the lower limbs was treated only symptomatically, often not in accordance with the logic and sequence of deterioration of the successive floors of the venous system (the so-called 'top down'). non-haemodynamic treatment, i.e. incompatible with the physics of fluids - in this case circulating blood).

A proper therapeutic approach therefore requires the initiation of treatment for pelvic venous disease (STAGE 1.), e.g. using venous embolisation to eliminate reflux in insufficient ovarian veins or the iliac placenta. The use of modern embolisation techniques makes it possible to effectively reduce venous pressure in the pelvic area. Only once the main source of venous stasis and/or venous outflow disorder has been controlled can the (STAGE 2.) topical treatment of varicose veins in the intimate area and venous leakage from the pelvis into the veins of the lower limbs.

This is analogous to the situation in everyday life where the main water valve should be shut off first and only then proceed to repair leaking pipes in the plumbing and a flooded flat. In the case of the venous system, attempting to treat varicose veins locally without first controlling the insufficiency of the main venous trunks most often results in failure or recurrence of venous disease.

The final stage (STAGE 3.) involves treating venous insufficiency of the lower limbs in a minimally invasive manner and sparing as many venous trunks as possible. This innovative treatment strategy significantly increases the effectiveness of venous disease treatment compared to the traditional approach focusing mainly on treating symptoms. The undoubted advantage of sequential causal treatment is the possibility of avoiding a significant percentage of unnecessary venous interventions in the lower limb venous system. With more than 10-year follow-up by doctors at the Phlebology Clinic shows that in some patients, after treatment of pelvic venous insufficiency, healing of venous leaks and varicose veins of the intimate area, there is spontaneous regression of symptoms and reduction of venous reflux in the main limbic venous axes. This saves many venous trunks that used to be unnecessarily and irreversibly removed or closed using intravenous techniques.

Pelvic venous insufficiency - what should every woman know about its symptoms?

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