Varicose veins of the pelvis

Varicose veins of the pelvis- ectasia of the vessels of the venous system of the pelvis, which leads to an impairment of blood flow from the internal and external genital organs. It is manifested in a visible expansion of the perineal and vulvar veins, accompanied by local edema, a feeling of heaviness and bursting pain, bleeding. Pelvic pain, dysmenorrhea, dyspareunia, and other symptoms are characteristic. Varicose veins of the small pelvis are diagnosed by gynecological examination and ultrasound with CDC, venography, CT, laparoscopy. Treatment of the syndrome can be conservative (taking venotonics, exercise therapy) or surgical (sclerobliteration / embolization of the gonadal veins, phlebectomy, etc. ).

Varicose veins of the small pelvis

Pelvic varicose veins (VVVMT) are a disease of the pelvic veins associated with a violation of their architecture and stagnation of venous blood in the pelvis. In the literature, varicose veins of the pelvis are also referred to by the terms "syndrome of venous congestion of the pelvis", "varicocele in women", "syndrome of chronic pelvic pain".Varicose veins of the pelvisThe prevalence of varicose veins in the pelvis increases proportionally with age: from 19. 4% in girls under 17 to 80% in women in perimenopause. Most often, the pathology of the pelvic veins is diagnosed in the reproductive period in patients in the age group from 25 to 45 years. In the vast majority of cases (80%), varicose vein conversion affects the ovarian veins and is extremely rarely (1%) observed in the veins of the broad ligament of the uterus. According to modern medical approaches, the treatment of VVMT should not be so much from the point of view of gynecology, but above all from the point of view of phlebology.

Causes of BPMT

The pathomorphological basis of the varicose veins of the pelvis is connective tissue dysplasia, which occurs in 35% of practically healthy people. This condition is congenital and characterized by a decrease in the content of some types of collagen, which leads to a decrease in the strength of connective tissue, including that that makes up the vascular wall. Extreme manifestation of such a pathology can be an underdevelopment or lack of a morphological component of the vascular wall. Systemic damage to connective tissue explains the frequent combination of VVMT with varicose veins of the lower extremities and hemorrhoids. In addition to connective tissue dysplasia, some "weakening" of the tone of the pelvic venous system in women is exerted by sex hormones (mainly progesterone), PGD, and pelvic vein thrombosis.

The factors that increase the risk of pelvic varicose veins are vigorous physical activity; Work in connection with the forced long-term stay while standing or sitting; Pregnancy and childbirth, pelvic injury, lack of orgasm in a woman. Among the gynecological diseases, endometriosis, prolapse of the vagina and uterus, tumors of the uterus and ovaries, retroflexion of the uterus, etc. , have the greatest influence on the development of VVMT. The starting role of hormonal contraception and hormone replacement therapy is not excluded.

BPVMT classification

Varicose veins of the pelvis can manifest themselves in two forms: varicose veins of the vulva and perineum and the syndrome of venous congestion. In more than half of the cases, both forms cause and support the flow of one another. Isolated vulvar and perineal varicose veins often result from the backflow of blood through the saphenofemoral anastomosis with damage to the external genital vein and influx of the great saphenous vein. It occurs in 30% of pregnant women, after giving birth it persists in 2-10% of women. The main factor behind varicose veins of the perineum and vulva is the pressure of the growing uterus on the iliac and inferior vena cava. The pathological condition for varicose veins of the pelvis is the backflow of blood through the ovarian vein.

There are 3 degrees of severity of varicose veins of the pelvis, taking into account the diameter and location of the venous ectasia:

  • 1 degree- enlarged vessels have a diameter of up to 0. 5 cm and a tortuous course; The lesion can affect any of the venous plexuses of the pelvis.
  • 2 degrees- enlarged vessels have a diameter of 0. 6-1 cm; The defeat can be total in nature or affect the ovarian plexus or parametric veins or arched veins of the myometrium.
  • 3 degrees- dilated vessels have a diameter of more than 1 cm with varicose veins of the total type or the main type (parametric localization).

BPVMT symptoms

The basis of the clinical picture of the vulvar and perineal varicose veins is the visible enlargement of the venous vessels in this area. Subjective complaints can include itching, discomfort, heaviness, and bursting pain in the external genital area. Upon examination, swelling of the labia may be found. Possibly the addition of spontaneous or post-traumatic bleeding, more commonly caused by sexual intercourse or childbirth. Due to the thinning of the vein wall and the high pressure in the varicose veins, stopping such bleeding is fraught with certain difficulties. Another complication of varicose veins of this localization can be acute thrombophlebitis of the veins of the perineum. In this case, severe pain, hyperemia and edema of the skin of the perineum appear. Veins affected by varicose veins feel tight and painful to the touch. Hyperthermic syndrome develops - an increase in body temperature to 37, 5-38, 0 ° C.

Another form of pelvic varicose veins - venous congestion syndrome - can result in a polymorphic clinical picture and is therefore often confused with inflammatory gynecological pathology, colitis, cystitis, lumbosacral sciatica, etc. The most constant symptom are pain in the lower part of the abdomen with different intensity, character and radiation. More often, patients describe their sensations as aching pain radiating to the lumbosacral region, groin, or perineum. Almost half of women with pelvic varicose veins notice an increase in pain during the second phase of the menstrual cycle. Pain is often caused by sexual intercourse, prolonged sitting or standing, physical exertion. The presence of pronounced premenstrual syndrome, algomenorrhea, dyspareunia, and dysuric disorders are typical of the syndrome of venous congestion of the pelvis.

BPVMT diagnosis

Diagnosis of pelvic varicose veins consists of a standard gynecological examination, ultrasound examination of the OMT and the veins of the lower extremities, pelvic phlebography, CT examination of the pelvis, laparoscopy. A gynecologist and a phlebologist should be involved in evaluating patients with suspected VVMT.

Examination of the external genitalia reveals dilated superficial veins in the vulva and perineum. During a vaginal examination, cyanosis of the vaginal walls is detected, pain when palpating the abdomen. Ultrasonography of the pelvic organs enables VVMT to be confirmed, while the combined ultrasound TA + TV approach is the most informative. The study allows not only the identification of an organic pathology, but also the use of the CDC mode to detect conglomerates of varicose veins with altered blood flow and pathological blood reflux. According to the USDG data of the vessels, a decrease in the maximum speed of blood flow in the veins of the uterus, ovaries and internal pelvis is determined. As part of the assessment of the patient's phlebological status, it is advisable to conduct an ultrasound angioscan examination of the veins of the lower extremities.

In order to examine the localization and prevalence of varicose veins of the pelvis, the condition of the valve system and the venous anastomoses, as well as the detection of blood clots, a transuterine venography is performed. In the syndrome of venous fullness, selective ovariancography, in which contrast agents are introduced directly into the ovarian veins, may be indicated. For isolated vulvar-perineal varicose veins, varicography is used - in contrast to the veins of the perineum. Currently, X-ray contrast studies are being replaced by CT of the pelvic organs, which is not inferior to them in diagnostic value. In the context of differential diagnostics and in the case of insufficient information content of the listed methods, they resort to diagnostic laparoscopy.

Treatment of BPHMT

During pregnancy, only symptomatic therapy of the varicose veins of the pelvis is possible. It is recommended to wear compression tights and take phlebotonics (diosmin, hesperidin) on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of the varicose veins of the perineum can be performed. If there is a high risk of bleeding due to varicose veins during spontaneous delivery, the choice is made in favor of a surgical delivery.

Conservative tactics can be effective for grades 1-2 ERCT. Taking venoactive and antiplatelet drugs, NSAIDs, exercise therapy, ascending contrast shower, normalization of working conditions and physical activity, selection of compression stockings and other measures can slow the progression of varicose veins and significantly improve well-being. If abnormal uterine bleeding occurs, hemostatic therapy is prescribed. In some cases, the patient may need the help of a psychotherapist.

The uncontrolled pain syndrome and 3rd degree varicose veins of the small pelvis serve as an indication for the surgical treatment of the pathology. Modern methods of minimally invasive surgery include sclerobliteration or embolization of the ovarian veins, which are performed under angiographic control. During the procedure, a sclerosant is injected into the lumen of the vessel under local anesthesia or an embolization coil is installed, which obliterates / occludes the gonadal vein. A possible alternative is resection of the ovarian veins using a laparotomic or retroperitoneal approach or their endoscopic cutting. If the retroflexion of the uterus is the cause of VVMT, then the plasticity of the ligamentous apparatus is carried out.

For isolated vulvar and perineal varicose veins, a miniflebectomy or phlebectomy can be performed in the perineum. The surgery is often complemented by a resection of the labia minora or majora. If there is a combination of varicose veins of the perineum and lower extremities, a crossectomy is indicated.

Prevention of BPHMT

Preventive measures to reduce the risk of the appearance and progression of varicose veins of the pelvis are mainly limited to the normalization of lifestyle. In this series, the main role is to eliminate prolonged static and heavy physical exertion, correct diet (including a large amount of fruits and vegetables), and quit alcohol and smoking. At the first signs of varicose veins, therapeutic gymnastics and breathing exercises, wearing compression stockings, as well as preventive and recurrent courses of conservative therapy are recommended. In this case, it is possible to achieve long-term remission and improve the quality of life for patients.