Exploring Innovative Treatment Options for Pelvic Varices

Pelvic varices are a type of pelvic venous insufficiency and refer to dilated veins with reflux. They occur due to an obstruction to the blood flow in the renal vein, ovarian vein, or iliac vein, causing reflux and vascular overload that congest the veins in the pelvis. They are the most common expression of pelvic venous insufficiency, but not the only one. Other types include malformations and varicoceles, which concern the veins around the ovary and parametrium and are not synonymous with pelvic varices.

Pelvic varices are common in multiparous women, and it is thought that after three or four pregnancies, they are practically constant. But only about 10% lead to pelvic congestion syndrome, a certain number of abdominal and pelvic symptoms related to these venous phenomena.

Pelvic varices are usually asymptomatic, but in 10% of cases they can be symptomatic, either in the pelvic floor or in the lower limbs, and require treatment. Pelvic congestion syndrome is related to venous hypertension, causing irritation to neighboring organs and creating symptoms. Patients may experience major functional repercussions and, in some cases, disability.

Symptoms include chronic pelvic pain, deep and experienced as cramps, burning, and stabbing sensations, perineal heaviness, and lower limb varicose veins. The pain can be intermittent or permanent, triggered by certain efforts such as standing for long periods, carrying heavy loads. It is mediated by the location of the varicose veins, which can be multiple and polymorphic.

Pelvic varices, being varicose veins, are a concern for vascular doctors. Vascular doctors have long recognized the supply of perineal veins through varicose veins, and direct connections between the pelvic veins and veins of the lower limbs have been found. A leak point is an inversion of the flow in an anatomical drainage pathway that can link pelvic varices with the lower limbs.

Pelvic venous Doppler ultrasound is the recommended first-line examination for diagnosing pelvic varices. It is used to confirm the positive diagnosis of pelvic varices, classify them, quantify them, and detect leak points, such as those in the ovarian vein, as well as compression points, including Nut-Cracker syndrome. Pelvic venous ultrasound is also used to diagnose lateral uterine varicose veins, sciatic nerve varices, and superficial systematized leak points. A venogram is usually done by specialists such as a vascular doctor, and it comes after the ultrasound. Endovascular treatment, which is exclusively endovascular and complicated for a vascular surgeon or gynecologist, is highly efficacious in treating varicose veins, especially with a long-term effect of nearly 83 to 85% recovery or significant improvement in patients.

An endovaginal probe may provide better image resolution for latero-uterine varicose veins, but perineal exploration remains the gold standard for identifying pelvic-perineal leak points. Vulvar varicose veins during pregnancy can be relieved through compression with devices designed for lymphedema, such as fractionated foam chip pads held in place with maternity compression tights.

Last, but not least: Pelvic varices in men exist and are caused by similar anatomical factors as in women, including Nut-Cracker syndrome and May-Thurner syndrome. The most common type of pelvic varices in men is varicocele, which can be identified by looking for reflux in the Giacomini anastomosis.