Vulval varices - Clinicals, Diagnosis, and Management

Obstetrics

Clinicals - History

Fact Explanation
Pelvic discomfort Vulval varicosity is a distressing disorder occurring in 10% of pregnant women, generally during the latter half of a second pregnancy and usually regresses postpartum. It may produce pelvic discomfort.. Women become extremely uncomfortable because
of the bulk, tension, and warmth of one or both labia majora, especially in the posterior part. And also the mass is an embarrassment and a discomfort
during sitting-and walking..
Pelvic discomfort
Vulval varicosity is a distressing disorder occurring in 10% of pregnant women, generally during the latter half of a second pregnancy and usually regresses postpartum. It may produce pelvic discomfort.. Women become extremely uncomfortable because
of the bulk, tension, and warmth of one or both labia majora, especially in the posterior part. And also the mass is an embarrassment and a discomfort
during sitting-and walking..
Vulvar pressure and heaviness Maybe seen in vulval varices. heaviness and swelling increase on standing and reduce in the lying down position.. Vulvar pressure and heaviness
Maybe seen in vulval varices. heaviness and swelling increase on standing and reduce in the lying down position..
Pruritus Some may experience pruritus in vulval area.. Pruritus
Some may experience pruritus in vulval area..
Sensation of prolapse Vulval varices may produce pelvic discomfort, vulvar pressure, pruritus, a sensation of prolapse, and may extend into the vagina.. Sensation of prolapse
Vulval varices may produce pelvic discomfort, vulvar pressure, pruritus, a sensation of prolapse, and may extend into the vagina..
Extend into the vagina Hormonal influences, prostaglandins A1, A2, E1, and E2, and scarcity of valves in the pelvic veins facilitating free and profuse crossover circulation lead to increased chances of vulvar varicosities in pregnancy, usually apparent after 26 weeks of gestation.The anastomotic nature of the venous network can result in downward extensions to the vagina and the medial aspect of the thigh, anteriorly to the groin and mons veneris, and posteriorly to the anal margin.. Extend into the vagina
Hormonal influences, prostaglandins A1, A2, E1, and E2, and scarcity of valves in the pelvic veins facilitating free and profuse crossover circulation lead to increased chances of vulvar varicosities in pregnancy, usually apparent after 26 weeks of gestation.The anastomotic nature of the venous network can result in downward extensions to the vagina and the medial aspect of the thigh, anteriorly to the groin and mons veneris, and posteriorly to the anal margin..
Thrombosis Complications such as thrombosis or bleeding can occur. But fortunately they are rare.. Thrombosis
Complications such as thrombosis or bleeding can occur. But fortunately they are rare..
Bleeding Spontaneous bleeding appears to be of academic interest, and in practice is not observed. Bleeding during childbirth is associated with vaginal tears or an episiotomy. Internal bleeding results in the formation of a hematoma, primarily.affecting the labia. And vulvar varices are not an indication for a cesarean section delivery.. Bleeding
Spontaneous bleeding appears to be of academic interest, and in practice is not observed. Bleeding during childbirth is associated with vaginal tears or an episiotomy. Internal bleeding results in the formation of a hematoma, primarily.affecting the labia. And vulvar varices are not an indication for a cesarean section delivery..
Pain Vulvar varicose veins are rare in non-pregnant women. When present, they can be seen alone, associated with leg varices, or associated with venous malformations of the labia, clitoral area or vagina. In this case the patient presented with vulval and upper thigh varices associated with pelvic heaviness and pain radiating down the leg.The association of varices plus chronic pelvic pain can be secondary to PCS (Pelvic congestion syndrome). . Pain
Vulvar varicose veins are rare in non-pregnant women. When present, they can be seen alone, associated with leg varices, or associated with venous malformations of the labia, clitoral area or vagina. In this case the patient presented with vulval and upper thigh varices associated with pelvic heaviness and pain radiating down the leg.The association of varices plus chronic pelvic pain can be secondary to PCS (Pelvic congestion syndrome). .
Dyspareunia It is estimated that over 30% of women will have chronic pelvic pain during life This chronic pelvic pain is often a manifestation of venous insufficiency of the gonadal and pelvic veins. In women, this is manifested by swelling in/of the vulva or vagina, as well as vulvar, buttock, and leg varicosities. Dyspareunia and abnormal menstrual bleeding might also result.. Dyspareunia
It is estimated that over 30% of women will have chronic pelvic pain during life This chronic pelvic pain is often a manifestation of venous insufficiency of the gonadal and pelvic veins. In women, this is manifested by swelling in/of the vulva or vagina, as well as vulvar, buttock, and leg varicosities. Dyspareunia and abnormal menstrual bleeding might also result..

Clinicals - Examination

Fact Explanation
Dilated tortuous veins Partially compressible tortuous blue-colored swelling having a 'bag of worms feel' on palpation can be seen in labia majora, minora, and vagina .. Dilated tortuous veins
Partially compressible tortuous blue-colored swelling having a 'bag of worms feel' on palpation can be seen in labia majora, minora, and vagina ..
Vulval swelling Vulval veins may be distended from one
or more of three sources of hypertension. They are the long saphenous vein through
its incompetent tributaries, the superficial and deep external pubic veins and the spermatic veins passing with the round ligament from the labia majora into the inguinal canal and thence to the posterior abdominal wall to join the inferior venacava on the right and the renal vein on the left.
Their varicosity causes a bulge in the groin like an inguinal hernia, with an
increasing pear-shaped swelling of
the labium major on the affected side, attaining grotesque proportions in the perineum. And it causes disfigurement. third one is the pudendal tributaries
of the internal iliac vein also fill varices of the perineum,posterior part of the labia, and upper part of the postero-medial aspects of the thigh..
Vulval swelling
Vulval veins may be distended from one
or more of three sources of hypertension. They are the long saphenous vein through
its incompetent tributaries, the superficial and deep external pubic veins and the spermatic veins passing with the round ligament from the labia majora into the inguinal canal and thence to the posterior abdominal wall to join the inferior venacava on the right and the renal vein on the left.
Their varicosity causes a bulge in the groin like an inguinal hernia, with an
increasing pear-shaped swelling of
the labium major on the affected side, attaining grotesque proportions in the perineum. And it causes disfigurement. third one is the pudendal tributaries
of the internal iliac vein also fill varices of the perineum,posterior part of the labia, and upper part of the postero-medial aspects of the thigh..
Cough impulse Varicosity of the long saphenous and round ligament veins together has been found. The varicose round ligament veins would correspond to a
varicocele of the spermatic veins in the male. They are denoted by a bulge in the inguinal canal, which steadily
enlarges to the labium major and perineum. There is an impulse in these veins on coughing. Compression empties them, and they are largely controlled after emptying by pressure with the finger over the internal
ring when the swelling remains smaller and softer, but reappears immediately the pressure is released. This control is not absolute, for there are usually contributory vessels frqm the long saphenous or pudendal veins..
Cough impulse
Varicosity of the long saphenous and round ligament veins together has been found. The varicose round ligament veins would correspond to a
varicocele of the spermatic veins in the male. They are denoted by a bulge in the inguinal canal, which steadily
enlarges to the labium major and perineum. There is an impulse in these veins on coughing. Compression empties them, and they are largely controlled after emptying by pressure with the finger over the internal
ring when the swelling remains smaller and softer, but reappears immediately the pressure is released. This control is not absolute, for there are usually contributory vessels frqm the long saphenous or pudendal veins..

Investigations - Diagnosis

Fact Explanation
Doppler sonography Doppler sonography with deep inspiration and expiration is the preferred method of investigation. During pregnancy, Doppler sonography is especially requested in some situations.they are early-onset vulvar varices (first two months of a first pregnancy), to look for a malformation,Unilateral vulvar varices (malformation, left iliac thrombosis) and Superficial thrombosis of a vulvar varicose vein, to look for deep vein thrombosis.. Doppler sonography
Doppler sonography with deep inspiration and expiration is the preferred method of investigation. During pregnancy, Doppler sonography is especially requested in some situations.they are early-onset vulvar varices (first two months of a first pregnancy), to look for a malformation,Unilateral vulvar varices (malformation, left iliac thrombosis) and Superficial thrombosis of a vulvar varicose vein, to look for deep vein thrombosis..
Laparoscopy It is an invasive investigation. It is used especially preoperatively to accurately delineate the varices.. Laparoscopy
It is an invasive investigation. It is used especially preoperatively to accurately delineate the varices..
Venography Varicose veins in the vulvar and peri-vulvar area are seen in 4% of women and most commonly seen during pregnancy. It is thought to be as a direct result of the presence of ovarian and pelvic varicosities. Diagnostic modalities used in the investigation of this condition included computed venography, magnetic resonance venography and catheter-directed venography.Catheter venography is invasive and is used to confirm the diagnosis immediately before embolization. There are characteristic findings on radiological imaging. Assessed on venography. Specific findings include an ovarian vein diameter of >10 mm along with congestion of the ovarian plexus. The reflux of blood and dilatation of the veins is due to an absence of functioning valves, particularly in the ovarian veins. However, there are other veins that can be responsible for vulval varicosities.Rarely from superficial external pudendal vein.. Venography
Varicose veins in the vulvar and peri-vulvar area are seen in 4% of women and most commonly seen during pregnancy. It is thought to be as a direct result of the presence of ovarian and pelvic varicosities. Diagnostic modalities used in the investigation of this condition included computed venography, magnetic resonance venography and catheter-directed venography.Catheter venography is invasive and is used to confirm the diagnosis immediately before embolization. There are characteristic findings on radiological imaging. Assessed on venography. Specific findings include an ovarian vein diameter of >10 mm along with congestion of the ovarian plexus. The reflux of blood and dilatation of the veins is due to an absence of functioning valves, particularly in the ovarian veins. However, there are other veins that can be responsible for vulval varicosities.Rarely from superficial external pudendal vein..
Pelvic Ultrasound Pelvic ultrasound is another diagnostic modality used in the investigation of this condition.Both transabdominal and transvaginal Ultrasound are used.. Pelvic Ultrasound
Pelvic ultrasound is another diagnostic modality used in the investigation of this condition.Both transabdominal and transvaginal Ultrasound are used..

Management - Supportive

Fact Explanation
Conservative measures As the varicosities tend to regress postpartum, the management is essentially conservative in the form of leg elevation, left-sided sleeping, compression hose, exercise, and the avoidance of sustained periods of sitting or standing.. Conservative measures
As the varicosities tend to regress postpartum, the management is essentially conservative in the form of leg elevation, left-sided sleeping, compression hose, exercise, and the avoidance of sustained periods of sitting or standing..
Vulval compression/ Support Vulval varicosities have been so gross before the 30th week of gestation. The postnatal surgery in such cases would be easier than during pregnancy, is mistaken, since such vulval veins in the collapsed state are extremely difficult to identify and eradicate. So that
vulval support is the best practical treatment, and the usual practice is to advise the women to wear a fairly
tight disposable sanitary pad, which has the advantage of being hygienic, easily obtained, and cheap..
Vulval compression/ Support
Vulval varicosities have been so gross before the 30th week of gestation. The postnatal surgery in such cases would be easier than during pregnancy, is mistaken, since such vulval veins in the collapsed state are extremely difficult to identify and eradicate. So that
vulval support is the best practical treatment, and the usual practice is to advise the women to wear a fairly
tight disposable sanitary pad, which has the advantage of being hygienic, easily obtained, and cheap..
Sclerotherapy Active treatment, in the form of sclerotherapy (with 1% sodium tetradecyl sulfate, polidocanol, aetoxisclerol, and polyiodinated iodine) is deemed appropriate in postpartum patients in cases of Unsightly or very symptomatic varicosities, to the extent of immobilizing the patient with pain, particularly during the third trimester ,Superficial thrombophlebitis or Symptoms persisting beyond six weeks of the postpartum period (this appears to be a sufficient length of time to allow for spontaneous resolution).. Sclerotherapy
Active treatment, in the form of sclerotherapy (with 1% sodium tetradecyl sulfate, polidocanol, aetoxisclerol, and polyiodinated iodine) is deemed appropriate in postpartum patients in cases of Unsightly or very symptomatic varicosities, to the extent of immobilizing the patient with pain, particularly during the third trimester ,Superficial thrombophlebitis or Symptoms persisting beyond six weeks of the postpartum period (this appears to be a sufficient length of time to allow for spontaneous resolution)..
Sapheno femoral ligation Where clear signs of venous incompetence were found, which was causing considerable distress not relieved by other measures, operation has been advised, up to the end of the seventh month. Varicosity of the labium major requires exploration of the sapheno-femoral junction and its ligation if incompetent, together with the tributaries joining, followed by excision of the round ligament with the
associated distended veins. This is done under a bland general anaesthetic..
Sapheno femoral ligation
Where clear signs of venous incompetence were found, which was causing considerable distress not relieved by other measures, operation has been advised, up to the end of the seventh month. Varicosity of the labium major requires exploration of the sapheno-femoral junction and its ligation if incompetent, together with the tributaries joining, followed by excision of the round ligament with the
associated distended veins. This is done under a bland general anaesthetic..
Hysterectomy and/or ligation of ovarian veins The treatment options in the past were hysterectomy and/or ligation of ovarian veins by open or laparoscopic approach.. Hysterectomy and/or ligation of ovarian veins
The treatment options in the past were hysterectomy and/or ligation of ovarian veins by open or laparoscopic approach..
Laparoscopic ligation of the ovarian veins. The traditional treatment has been replaced with laparoscopic ligation of the ovarian veins. However, this approach can result in transaction of the nerves to the pelvis and still leave the possibility of establishing collateral channels resulting in symptomatic recurrence.. Laparoscopic ligation of the ovarian veins.
The traditional treatment has been replaced with laparoscopic ligation of the ovarian veins. However, this approach can result in transaction of the nerves to the pelvis and still leave the possibility of establishing collateral channels resulting in symptomatic recurrence..
Local excision Local excision can also be attempted. Left untreated, vulvar varicosities can persist and sometimes get worse in subsequent pregnancies.. Local excision
Local excision can also be attempted. Left untreated, vulvar varicosities can persist and sometimes get worse in subsequent pregnancies..

Management - Specific

Fact Explanation
Embolization of the varicosity The most commonly performed technique now is embolization of the responsible veins using interventional radiology. The technique was described by Edwards in 1993 and has gained popularity by both clinicians and patients. Transcatheter embolotherapy is now the preferred treatment for PCS. This is performed with a combination of sclerosant foam and/or coils to embolize the source veins. Clinical success is achieved in 70–85% of treated patients.. Embolization of the varicosity
The most commonly performed technique now is embolization of the responsible veins using interventional radiology. The technique was described by Edwards in 1993 and has gained popularity by both clinicians and patients. Transcatheter embolotherapy is now the preferred treatment for PCS. This is performed with a combination of sclerosant foam and/or coils to embolize the source veins. Clinical success is achieved in 70–85% of treated patients..

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. ASLAM M. I., FLEXER S. M., FIGUEIREDO R., ASHOUR H. Y., BHATTACHARYA V.. Successful embolization of vulval varices arising from the external pudendal vein. Journal of Surgical Case Reports [online] December, 2014(2):rjt129-rjt129 [viewed 19 August 2014] Available from: doi:10.1093/jscr/rjt129
  2. BEST IM. Management of an Unusual Iliac Fossa Venous Plexus Case Rep Vasc Med [online] 2011:140389 [viewed 19 August 2014] Available from: doi:10.1155/2011/140389
  3. DODD H, WRIGHT HP. Vulval Varicose Veins in Pregnancy Br Med J [online] 1959 Mar 28, 1(5125):831-832 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824
  4. DODD H, WRIGHT HP. Vulval Varicosities in Pregnancy Br Med J [online] 1959 May 30, 1(5134):1412 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993582
  5. JINDAL S, DEDHIA A, TAMBE S, JERAJANI H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic Indian J Dermatol [online] 2014, 59(2):210 [viewed 18 August 2014] Available from: doi:10.4103/0019-5154.127757