What will dilated veins in the small pelvis reveal in women?

With the article, you will learn the characteristics of varicose veins in the small pelvis in women - it is a deformation of the veins in the pelvic region with impaired blood flow to the internal and external genitals.

General information

In the literature, small pelvic varicose veins are also called "pelvic congestion syndrome", "variocele in women", "chronic pelvic pain syndrome". The prevalence of varicose veins in the small pelvis increases in proportion to age: from 19. 4% in girls under 17 to 80% in perimenopausal women. Most often, pelvic vein pathology is diagnosed during the reproductive period in patients aged 25-45 years.

In the overwhelming majority of cases (80%), transformation of varices affects the ovarian veins and is extremely rare (1%) seen in the veins of the large ligament of the uterus. According to modern medical approaches, the treatment of VVMT should be carried out not so much from a gynecology point of view, but rather from a phlebology point of view.

Pathology Triggers

Under pelvic organ varicose veins in women, doctors understand a change in the structure of the vascular walls that is characteristic of other types of the disease—weakening followed by stretching and formation of "pockets" within which the blood stagnates. Cases where only the vessels in the pelvic organs are affected are extremely rare. In about 80% of patients, along with this form, there are signs of varices in the inguinal veins, vessels of the lower extremities.

The incidence of varicose veins in the small pelvis is more pronounced in women. This is due to anatomical and physiological characteristics, suggesting a tendency to weaken the venous walls:

• hormonal fluctuations, including those associated with the menstrual cycle and pregnancy;
• increased pressure in the small pelvis, which is typical of pregnancy;
• periods of more active filling of the veins with blood, including cyclic menstrual periods, during pregnancy as well as during sexual intercourse.

All these phenomena belong to the category of factors that cause varicose veins. And they are found exclusively in women. The largest number of patients are faced with small pelvic varicose veins during pregnancy, as there is a simultaneous stratification of triggering factors. According to statistics, among men, varicose veins in the small pelvis are 7 times less common than in the weaker sex. They have a more diverse set of provocation factors:

• hypodynamic - long-term preservation of low physical activity;
• increased physical activity, especially dragging weights;
• obesity;
• lack of enough fiber in the diet;
• inflammatory processes in the organs of the genitourinary system;
• sexual dysfunction or lucid refusal to have sex.

A genetic predisposition can also lead to pathology of the plexuses located within the small pelvis. According to statistics, varicose veins in the perineum and pelvic organs are more often diagnosed in women whose relatives suffered from this disease. The first changes in them can be seen in adolescence during puberty.

The greatest risk of developing inguinal varices in women with pelvic vessel involvement is seen in patients with venous pathology elsewhere in the body. In this case, we are talking about congenital weakness of the veins.

Etiopathogenesis

Proctologists believe that the following main reasons always contribute to the occurrence of VVP: valve insufficiency, venous obstruction, and hormonal changes.

Pelvic venous congestion syndrome can develop from the congenital absence or insufficiency of the venous valves, which was revealed by anatomical studies in the last century, and modern data confirm this.

It was also found that in 50% of patients varicose veins are genetic in nature. FOXC2 was one of the first genes identified that play a key role in the development of VVP. Currently, the relationship between disease development and genetic mutations (TIE2, NOTCH3), thrombomodulin level and transforming growth factor type 2 β have been determined. These factors contribute to a change in the structure of the valve itself or in the venous wall - all of which lead to failure of the valve structure; widening of the vein, which causes changes in valve function; to progressive reflux and, finally, to varicose veins.

An important role in the development of the disease can be played by connective tissue dysplasia, whose morphological basis is the decrease in the content of various types of collagen or the violation of the ratio between them, which leads to a decrease in the resistance of the veins.

The incidence of VVP is directly proportional to the amount of hormonal changes, which are especially pronounced during pregnancy. In pregnant women, the capacity of the pelvic veins increases by 60% due to the mechanical compression of the pelvic vessels by the pregnant uterus and the vasodilatory effect of progesterone. This venous dilation persists for a month after delivery and can cause venous valve failure. Furthermore, during pregnancy, the mass of the uterus increases, its positional changes occur, which causes elongation of the ovarian veins, followed by venous congestion.

Risk factors also include endometriosis and other inflammatory diseases of the female reproductive system, estrogen therapy, adverse working conditions for pregnant women, which include heavy physical work and prolonged forced posture (sitting or standing) during the working day.

The formation of varicose veins in the small pelvis is also facilitated by the anatomical characteristics of the flow of veins in the small pelvis. The diameter of the ovarian veins is usually 3-4 mm. The long, thin ovarian vein on the left flows into the left renal vein and on the right into the inferior vena cava. Typically, the left renal vein is located in front of the aorta and behind the superior mesenteric artery. The physiological angle between the aorta and the superior mesenteric artery is approximately 90°.

This normal anatomical position prevents compression of the left renal vein. On average, the angle between the aorta and the superior mesenteric artery in adults is 51 ± 25 ° in children - 45, 8 ± 18, 2 ° in boys and 45, 3 ± 21, 6 ° in girls. In case the angle decreases from 39, 3 ± 4, 3 ° to 14, 5 °, there is aortomesenteric compression or nutcracker syndrome. It is the so-called anterior, or true, nutcracker syndrome that has the greatest clinical significance. Posterior nutcracker syndrome occurs on rare occasions in patients with a retroaortic or annular arrangement of the distal left renal vein. Obstruction of the proximal venous bed causes increased pressure in the renal vein, which leads to the formation of renoovarian reflux in the left ovarian vein, with the development of chronic pelvic venous insufficiency.

May-Turner syndrome - compression of the left common iliac vein by the right common iliac artery - also acts as one of the etiologic factors of varicose veins in the pelvis. It occurs in no more than 3% of cases and is more frequent in women. Currently, with the introduction of radiation and endovascular imaging methods into practice, this pathology is being detected more and more frequently.

Classification

Varicose veins are subdivided in the following ways:

• The main type of varicose veins: an increase in blood vessels in the pelvis. The reason is valve insufficiency of 2 types: acquired or congenital.
• The secondary form of pelvic vein thickening is diagnosed exclusively in the presence of pathologies in terms of gynecology (endometriosis, neoplasms, polycystic).

Varicose veins in the pelvis develop gradually. In medical practice, there are several major stages in the development of the disease. They will differ depending on the presence of complications and the spread of the disease:

• First degree. Changes in the structure of ovarian vein valves can occur for hereditary reasons or be acquired. The disease is characterized by an increase in the diameter of the veins of up to 5 mm. The left ovary has a pronounced expansion on the outside.
• High school. This grade is characterized by spread of the pathology and damage to the left ovary. The veins in the uterus and right ovary may also be dilated. The expansion diameter reaches 10 mm.
• Third degree. The diameter of the veins increases up to 1 cm. Expansion of the veins is seen equally in the right and left ovaries. This phase is due to pathological phenomena of a gynecological nature.

It is also possible to classify the disease according to the primary cause of its development. There is a primary degree, in which the expansion is caused by defective functioning of the venous valves, and a secondary degree, which is the consequence of chronic female diseases, inflammatory processes or complications of an oncological nature. The degree of the disease may differ according to the anatomical characteristic, which indicates the location of the vascular disorder:

• Intra-caste plethora.
• Vulvar and perineal.
• Combined forms.

Symptoms and clinical manifestations

In women, pelvic varices are accompanied by severe but nonspecific symptoms. Manifestations of this disease are often considered signs of gynecological disturbances. The main clinical symptoms of varicose veins in the groin in women with pelvic vessel involvement are:

• Non-menstrual pain in the lower abdomen. Its intensity depends on the stage of venous damage and the extent of the process. For first-degree varicose veins of the small pelvis, periodic mild pain extending to the lower back is characteristic. In later stages it is felt in the abdomen, perineum and lower back and is long and intense.
• Profuse mucous secretion. The so-called leukorrhea does not have an unpleasant smell, does not change color, which would indicate an infection. The discharge volume increases in the second phase of the cycle.
• Increased symptoms of premenstrual syndrome and dysmenorrhea. Even before menstruation begins, pain in women increases, until the occurrence of difficulties in walking. During menstrual bleeding, it can become unbearable, spreading to the entire pelvic area, perineum, lower back, and even the thighs.
• Another characteristic sign of varicose veins in the groin in women is discomfort during intercourse. It is felt in the vulva and vagina and is characterized as a dull pain. This can be seen at the end of intercourse. Furthermore, the disease is accompanied by increased anxiety, irritability and mood swings.
• As with small pelvic varicose veins in men, in the female part of patients with this diagnosis, interest in sex gradually disappears. The cause of the dysfunction is constant discomfort and a decrease in the production of sex hormones. In some cases, infertility can occur.

instrumental diagnostics

The diagnosis and treatment of varicose veins are performed by a phlebologist, vascular surgeon. Currently, the number of cases of detection of VVP has increased due to new technologies. Patients with PCP are seen at various stages.

• The first stage is a routine examination by a gynecologist: taking history, manual examination, ultrasound examination of the pelvic organs (to exclude other pathology). Based on the results, an exam is additionally prescribed by a proctologist, urologist, neurologist and other related specialists.
• If the diagnosis is unclear, but DVT is suspected, in the second stage, angiosomnography (USAS) of the pelvic veins is performed. This is a non-invasive and highly informative diagnostic screening method that is used in all women with suspected PTVV. If previously it was believed that it was enough to examine only the pelvic organs (examination of the veins was considered difficult to access and optional), then, at the current stage, ultrasonography of the pelvic veins is a mandatory exam. With the help of this method, it is possible to establish the presence of small pelvic varices by measuring the diameters, the velocity of blood flow in the veins and, preliminarily, discovering the main pathogenic mechanism - the failure of the ovarian veins or venous obstruction. In addition, this method is used for dynamic assessment of conservative and surgical treatment of VVPT.
• The research is carried out via transvaginal and transabdominal routes. The parametrium veins, groin-like plexuses, and uterine veins are visualized transvaginally. According to several authors, the diameter of the vessels in the named locations varies from 2. 0 to 5. 0 mm (on average 3. 9 ± 0. 5 mm), that is, no more than 5 mm, and the mean diameter of the veins arcuate is 1. 1 ± 0. 4 mm. Veins larger than 5 mm in diameter are considered dilated. The inferior vena cava, iliac veins, left renal vein, and ovarian veins are examined transabdominally to exclude thrombotic masses and extravasal compression. The length of the left renal vein is 6 to 10 mm and its average width is 4 to 5 mm. Normally, the left renal vein where it passes over the aorta is somewhat flattened, but there is a 2–2. 5-fold decrease in its transverse diameter without a significant acceleration of blood flow, which ensures normal flow without increasing the pressure in the prehypotenotic zone. In the case of stenosis of a vein in the context of pathological compression, there is a significant decrease in its diameter - from 3, 5 to 4 times and an acceleration of blood flow - above 100 cm / s. The sensitivity and specificity of this method are 78 and 100%, respectively.
• Examination of the ovarian veins is included in the mandatory examination of the pelvic veins. They are located along the anterior abdominal wall, along the rectus abdominis muscle, slightly lateral to the iliac veins and arteries. A sign of ovarian vein failure in the USAS is considered to be greater than 5 mm in diameter with the presence of retrograde blood flow. For a complete examination, prevention of relapses and correct treatment tactics, ultrasound of the veins of the lower extremities, perineum, vulva, inner thigh and gluteal region should be performed.
• The development of medical technology has led to the use of new diagnostic methods. In the third step, after ultrasound verification of the diagnosis, radiation diagnosis methods are used to confirm it.
• Pelvic phlebography with bilateral selective radiopaque ovaricography is one of the invasive diagnostic methods by radiation that is performed only in a hospital environment. This method has long been considered the diagnostic "gold standard" for assessing dilation and detecting valve insufficiency in the pelvic veins. The essence of the method is the introduction of a contrast agent under the control of an X-ray installation through a catheter installed in one of the main veins (jugular, brachial or femoral) to the iliac, renal and ovarian veins. Thus, it is possible to identify the anatomical variants of the structure of the ovarian veins, to determine the diameters of the gonadal and pelvic veins.
• The retrograde contrast of the gonadal veins at the time of the Valsalva test serves as a pathognomonic angiographic sign of your valve insufficiency with visualization of marked expansion and tortuosity, respectively. This is the most accurate method to detect May-Turner syndrome, post-thrombophlebitic changes in the iliac and inferior vena cava.
• When the left renal vein is compressed, perirenal venous collaterals with retrograde blood flow to the gonadal veins, contrast stagnation in the renal vein is determined. The method measures the pressure gradient between the left and inferior renal vena cava. Typically this is 1 mm Hg. Art. ; gradient equal to 2 mm Hg. Art. , May suggest light compression; with a gradient>3 mm Hg. Art. can be diagnosed with aortomesenteric compression syndrome with hypertension in the left renal vein and gradient>5 mm Hg. Art. is considered a hemodynamically significant stenosis of the left renal vein. The determination of the pressure gradient is an important diagnostic element, since, depending on its values, essentially different surgical interventions are foreseen in the small pelvic veins, which is very important in modern conditions. Currently, this study (with a normal pressure gradient) can be used for therapeutic purposes - for ovarian vein embolization.
• The next method of radiation is emission computed tomography of the pelvic veins with in vitro labeled erythrocytes. It is characterized by the deposition of erythrocytes marked in the pelvic veins and visualization of the gonadal veins, allows the identification of varicose plexuses of the small pelvis and ovarian veins dilated in various positions, degree of pelvic venous congestion, blood reflux from the pelvic veins in the saphenous veins of the legs and perineum. Normally, the ovarian veins are not contrasted, there is no accumulation of radiopharmaceutical in the venous plexuses. For an objective assessment of the degree of venous congestion of the small pelvis, the pelvic venous congestion coefficient is calculated. But this method also has disadvantages: invasiveness, relatively low spatial resolution, inability to accurately determine the diameter of veins, so it is currently not used as much in clinics.
• The videolaparoscopy exam is a valuable tool in the evaluation of undiagnosed people. In combination with other methods, it can help determine the causes of pain and prescribe the correct treatment. With the varicose veins of the small pelvis in the ovarian region, along the wide, round ligaments of the uterus, the veins can be visualized as dilated cyanotic vessels with a tight, thin wall. The use of this method is significantly limited by the following factors: presence of retroperitoneal fatty tissue, possibility of evaluating varicose veins only in a limited area, and impossibility of determining venous reflux. Currently, the use of this method has diagnostic justification in cases of suspected multifocal pain. Laparoscopy allows us to visualize the causes of CPP, for example, endometriosis foci or adhesions, in 66% of cases.

therapy characteristics

For the complete treatment of small pelvic varicose veins, the woman must follow all the doctor's recommendations and also change her lifestyle. First, attention must be paid to the loads, if they are excessively high, they must be reduced, if the patient leads an excessively sedentary lifestyle, it is necessary to play sports, walk more frequently, etc.

Patients with varicose veins are strongly advised to adjust their diet, consume as little junk food as possible (fried, smoked, large amounts of sweets, salty foods, etc. ), alcohol, caffeine. It is better to give preference to vegetables and fruits, dairy products, cereals.

In addition, as a prophylaxis of disease progression and for medicinal purposes, doctors prescribe the use of compression briefs for patients with varicose veins.

Medicines

ERCT therapy involves several important points:

• get rid of reverse venous blood flow;
• relief of disease symptoms;
• stabilization of vascular tone;
• improves blood circulation in tissues.

Preparations for varicose veins should be done during the course. The rest of the drugs, which play the role of pain relievers, can be drunk exclusively during a painful attack. For effective therapy, the doctor often prescribes the following medications:

• phleboprotectors;
• enzyme preparations;
• drugs that alleviate inflammatory processes with varicose veins;
• pills to improve blood circulation.

surgical treatment

It is important to recognize that conservative treatment methods provide truly visible results, especially in the early stages of varicose veins. At the same time, the problem can be fundamentally resolved and the disease can be completely eliminated just by surgery. In modern medicine, there are many variations of surgical treatment of varicose veins, consider the most common and effective types of operations:

• embolization of veins in the ovaries;
• sclerotherapy;
• plastic of the uterine ligaments;
• removal of dilated veins by laparoscopy;
• clamping of veins in the small pelvis with special medical clips (clipping);
• crossectomy - vein ligation (prescribed if, in addition to the pelvic organs, vessels in the lower extremities are affected).

During pregnancy, only symptomatic therapy of small pelvic varicose veins is possible. We recommend the use of compression tights, taking phlebotonics on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of the perineal varicose veins can be performed. If, due to varicose veins, there is a high risk of bleeding during spontaneous delivery, the choice is made in favor of operative delivery.

Physiotherapy

The physical activity system for treating varicose veins in a woman consists of exercises:

• "Bicycle". We lie on our back, place our hands behind our head or place them along the body. Lifting our legs, we make circular motions with them, as if we were pedaling a bicycle.
• "Birch". We sit face-up on any hard, comfortable surface. Raise your legs and start gently behind your head. Supporting your lower back with your hands and resting your elbows on the floor, slowly straighten your legs, lifting your body.
• "Scissors". The starting position is on the back. Raise closed legs slightly above floor level. We open the lower limbs to the sides, return and repeat.

possible complications

Why are varicose veins in the small pelvis dangerous? The following consequences of the disease are often recorded:

• inflammation of the uterus, its appendages;
• uterine bleeding;
• abnormalities in bladder function;
• the formation of venous thrombosis (a small percentage).

Prophylaxis

In order for varicose veins in the small pelvis to disappear as quickly as possible and in the future there will be no recurrence of pelvic organ pathology, it is worth following simple preventive rules:

• perform gymnastics exercises daily;
• prevent constipation;
• observe a diet, in which vegetable fiber must be present;
• don't stay in the same position for too long;
• take a perineum contrast bath;
• so that varicose veins do not appear, it is best to wear exceptionally comfortable clothes and shoes.

Preventive measures aimed at reducing the risk of the appearance and progression of varicose veins in the small pelvis are mainly reduced to lifestyle normalization.