From the article you will learn the features of varicose veins of the small pelvis in women - this is a deformation of the veins of the pelvic region with impaired blood flow in the internal and external genitals.
In the literature, varicose veins of the small pelvis are also referred to as "pelvic congestion syndrome", "varicocele 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, the pathology of the pelvic veins is diagnosed in the reproductive period in patients in the age group of 25-45 years.
In the overwhelming majority of cases (80%), varicose transformation affects the ovarian veins and is extremely rare (1%) observed in the veins of the broad ligament of the uterus. According to modern medical approaches, the treatment of VVMT should be carried out not so much from the standpoint of gynecology, but, first of all, from the standpoint of phlebology.
Under varicose veins of the pelvic organs in women, doctors understand a change in the structure of the vascular walls characteristic of other types of the disease - weakening followed by stretching and the formation of "pockets" inside which blood stagnates. Cases when only the vessels of the pelvic organs are affected are extremely rare. In about 80% of patients, along with this form, signs of varicose veins of the inguinal veins and vessels of the lower extremities are observed.
The incidence of varicose veins of the pelvic vessels is most pronounced in women. This is due to anatomical and physiological features, 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 for pregnancy;
- periods of more active filling of the veins with blood, including cyclic menstrual periods, during pregnancy, as well as during sex.
All of these phenomena belong to the category of factors provoking varicose veins. And they are found exclusively in women. The largest number of patients are faced with varicose veins of the small pelvis during pregnancy, since there is a simultaneous layering of provoking factors. According to statistics, among men, varicose veins of the small pelvis are 7 times less common than among the fairer sex. They have a more diverse set of provoking factors:
- hypodynamia - long-term preservation of low physical activity;
- increased physical activity, especially dragging weights;
- lack of sufficient 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 the pathology of the plexuses located inside the small pelvis. According to statistics, varicose veins of the perineum and pelvic organs are most often diagnosed in women whose relatives suffered from this ailment. The first changes in them can be observed in adolescence during puberty.
The greatest risk of developing inguinal varicose veins in women with involvement of the pelvic vessels is observed in patients with venous pathology in other parts of the body. In this case, we are talking about congenital weakness of the veins.
Proctologists believe that the following main reasons always contribute to the occurrence of VVP: valvular insufficiency, venous obstruction and hormonal changes.
The syndrome of pelvic venous congestion can develop due to the congenital absence or insufficiency of 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 of a genetic nature. FOXC2 was one of the first genes identified that play a key role in the development of VVP. Currently, the relationship between the development of the disease and gene mutations (TIE2, NOTCH3), the level of thrombomodulin and type 2 transforming growth factor β has been determined. These factors contribute to a change in the structure of the valve itself or the venous wall - all this leads to the failure of the valve structure; enlargement of the vein, which causes a change in valve function; to progressive reflux and ultimately to varicose veins.
An important role in the development of the disease can be played by connective tissue dysplasia, the morphological basis of which is a decrease in the content of various types of collagen or a violation of the ratio between them, which leads to a decrease in vein strength.
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 vasodilating effect of progesterone. This venous dilatation persists for a month after delivery and can cause venous valve failure. In addition, during pregnancy, the mass of the uterus increases, its positional changes occur, which causes stretching 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 hard physical labor and prolonged forced position (sitting or standing) during the working day.
The formation of varicose veins in the small pelvis is also facilitated by the anatomical features of the outflow from the veins of the small pelvis. The diameter of the ovarian veins is usually 3-4 mm. The long and thin ovarian vein on the left flows into the left renal vein, and on the right, into the inferior vena cava. Normally, 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 the case of a decrease in the angle from 39. 3 ± 4. 3 ° to 14. 5 °, aorto-mesenteric compression, or nutcracker syndrome, occurs. This is the so-called anterior, or true, nutcracker syndrome, which 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 an increase in pressure in the renal vein, which leads to the formation of reno-ovarian 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 serves as one of the etiological factors of varicose veins in the pelvis. It occurs in no more than 3% of cases, it is found more often in women. Currently, due to the introduction of radiation and endovascular imaging methods into practice, this pathology is being detected more and more often.
Varicose veins are subdivided into the following forms:
- The primary type of varicose veins: an increase in the blood vessels of the pelvis. The reason is valvular insufficiency of 2 types: acquired or congenital.
- The secondary form of thickening of the pelvic veins is diagnosed exclusively in the presence of pathologies in terms of gynecology (endometriosis, neoplasms, polycystic).
Varicose veins of the pelvis develop gradually. In medical practice, there are several main 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 the ovarian vein valves can occur for hereditary reasons or be acquired. The disease is characterized by an increase in the diameter of the veins up to 5 mm. The left ovary has a pronounced expansion in the outer parts.
- Second degree. This degree is characterized by the spread of 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. The expansion of the veins is observed on the right and left ovaries equally. This stage is due to pathological phenomena of a gynecological nature.
It is also possible to classify the disease depending on 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 a consequence of chronic female diseases, inflammatory processes or oncological complications. The degree of the disease can differ according to the anatomical feature, which indicates the location of the vascular disorder:
- Intra-caste plethora.
- Vulvar and perineal.
- Combined forms.
Symptoms and clinical manifestations
In women, pelvic varicose veins are accompanied by severe, but nonspecific symptoms. Often, the manifestations of this disease are regarded as signs of gynecological disorders. The main clinical symptoms of varicose veins in the groin in women with involvement of the pelvic vessels are:
- Non-menstrual pain in the lower abdomen. Their intensity depends on the stage of venous damage and the extent of the process. For the 1st degree of 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 characterized by duration and high intensity.
- Profuse mucous discharge. The so-called leucorrhoea does not have an unpleasant odor, does not change color, which would indicate an infection. The volume of discharge increases in the second phase of the cycle.
- Increased symptoms of premenstrual syndrome and dysmenorrhea. Even before the onset of menstruation, pain in women increases, up to the occurrence of difficulties with walking. During menstrual bleeding, it can become unbearable, spreading to the entire pelvic region, perineum, lower back, and even to the thighs.
- Another characteristic sign of varicose veins in the groin in women is discomfort during sexual intercourse. It is felt in the vulva and vagina and is characterized as a dull pain. It can be observed at the end of intercourse. In addition, the disease is accompanied by increased anxiety, irritability, and mood swings.
- As with varicose veins of the small pelvis in men, in the female part of patients with such a diagnosis, interest in sex gradually disappears. The cause of dysfunction is both constant discomfort and a decrease in the production of sex hormones. In some cases, infertility may occur.
The diagnosis and treatment of varicose veins is performed by a phlebologist, a vascular surgeon. Currently, the number of cases of detection of VVP has increased due to new technologies. Patients with CPP are examined in several stages.
- The first stage is a routine examination by a gynecologist: taking anamnesis, manual examination, ultrasound examination of the pelvic organs (to exclude other pathology). Based on the results, an examination is additionally prescribed by a proctologist, urologist, neurologist and other related specialists.
- If the diagnosis is not clear, but there is a suspicion of VVPT, at the second stage, ultrasound angioscanning (USAS) of the pelvic veins is performed. This is a non-invasive, highly informative method of screening diagnostics, which is used in all women with suspected VVPT. If earlier it was believed that it was enough to inspect only the pelvic organs (vein examination was considered difficult to access and optional), then at the present stage, ultrasonography of the pelvic veins is a mandatory examination procedure. With the help of this method, it is possible to establish the presence of varicose veins of the small pelvis by measuring the diameters, the velocity of blood flow in the veins, and preliminary to find out what is the leading pathogenetic mechanism - the failure of the ovarian veins or venous obstruction. Also, this method is used for dynamic assessment of conservative and surgical treatment of VVPT.
- Research is carried out transvaginally and transabdominally. The veins of the parametrium, groin-like plexuses, and uterine veins are visualized transvaginally. According to different authors, the diameter of the vessels of the named localizations ranges from 2. 0 to 5. 0 mm (on average 3. 9 ± 0. 5 mm), i. e. no more than 5 mm, and the average diameter of the arcuate veins 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 in order 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 at the site of its passage over the aorta is somewhat flattened, but a decrease in its transverse diameter by 2–2. 5 times occurs without significant acceleration of blood flow, which ensures normal outflow without increasing pressure in the pretenotic zone. In the case of stenosis of a vein against the background of pathological compression, there is a significant decrease in its diameter - by 3. 5–4 times and an acceleration of blood flow - over 100 cm / s. The sensitivity and specificity of this method is 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 USAS is considered to be more than 5 mm in diameter with the presence of retrograde blood flow. For a full examination, prevention of relapses and correct treatment tactics, ultrasonography of the veins of the lower extremities, perineum, vulva, inner thigh and gluteal region must be performed.
- The development of medical technology has led to the use of new diagnostic methods. At the third stage, after ultrasound verification of the diagnosis, radiation diagnostic methods are used to confirm it.
- Pelvic phlebography with selective bilateral radiopaque ovarycography is one of the radiation invasive diagnostic methods that is performed only in a hospital setting. This method has long been considered the diagnostic "gold standard" for evaluating dilatation and detecting valvular 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.
- Retrograde contrasting of the gonadal veins at the height of the Valsalva test serves as a pathognomonic angiographic sign of their valvular insufficiency with visualization of a sharp expansion and tortuosity, respectively. This is the most accurate method for detecting 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 into the gonadal veins, contrast stagnation in the renal vein are determined. The method measures the pressure gradient between the left renal and inferior vena cava. Normally, it is 1 mm Hg. Art . ; gradient equal to 2 mm Hg. Art. , may suggest mild compression; with a gradient> 3 mm Hg. Art. can be diagnosed with aorto-mesenteric compression syndrome with hypertension in the left renal vein, and the gradient> 5 mm Hg. Art. is considered a hemodynamically significant stenosis of the left renal vein. Determination of the pressure gradient is an important element of diagnosis, since depending on its values, essentially different surgical interventions on the veins of the small pelvis are planned, 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 radiation method is emission computed tomography of the pelvic veins with in vitro labeled erythrocytes. It is characterized by the deposition of labeled erythrocytes in the veins of the pelvis and visualization of the gonadal veins, allows to identify varicose plexuses of the small pelvis and dilated ovarian veins in various positions, the degree of pelvic venous congestion, reflux of blood from the pelvic veins into the saphenous veins of the legs and perineum. Normally, the ovarian veins are not contrasted, the accumulation of the radiopharmaceutical in the venous plexuses is not observed. For an objective assessment of the degree of venous congestion of the small pelvis, the coefficient of pelvic venous congestion is calculated. But this method also has disadvantages: invasiveness, relatively low spatial resolution, the impossibility of accurately determining the diameter of the veins, therefore, at present it is not so often used in clinics.
- Video laparoscopic examination is a valuable tool in evaluating the undiagnosed. In combination with other methods, it can help determine the causes of pain and prescribe the correct treatment. With varicose veins of the small pelvis in the ovarian region, along the round and wide ligaments of the uterus, veins can be visualized in the form of cyanotic, dilated vessels with a thinned and tense wall. The use of this method is significantly limited by the following factors: the presence of retroperitoneal fatty tissue, the possibility of assessing varicose veins only in a limited area, and the impossibility of determining reflux through the veins. Currently, the use of this method is diagnostically justified in cases of suspected multifocal pain. Laparoscopy allows visualizing the causes of CPP, for example, foci of endometriosis or adhesions, in 66% of cases.
Features of therapy
For a complete treatment of varicose veins of the small pelvis, a woman must follow all the doctor's recommendations, as well as change her lifestyle. First of all, you need to pay attention 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, take walks more often, etc.
Patients with varicose veins are strongly advised to adjust their diet, consume as little junk food as possible (fried, smoked, sweet in large quantities, salty, etc. ), alcohol, caffeine. It is better to give preference to vegetables and fruits, dairy products, cereals.
Also, as a prophylaxis for the progression of the disease and for medicinal purposes, doctors prescribe the wearing of compression underwear for patients with varicose veins.
Therapy of ERCT implies several important points:
- getting rid of the reverse flow of venous blood;
- relief of symptoms of the disease;
- stabilization of vascular tone;
- improved blood circulation in tissues.
Preparations for varicose veins should be taken in courses. The rest of the drugs, which play the role of painkillers, are allowed to be drunk exclusively during a painful attack. For effective therapy, the doctor often prescribes the following medications:
- enzyme preparations;
- drugs that relieve inflammatory processes with varicose veins;
- pills to improve blood circulation.
It is worth recognizing that conservative treatment methods give truly visible results mainly in the initial stages of varicose veins. At the same time, the problem can be fundamentally solved and the disease can be completely eliminated only by surgery. In modern medicine, there are many variations of the surgical treatment of varicose veins, consider the most common and effective types of operations:
- embolization of veins in the ovaries;
- plastic of the uterine ligaments;
- removal of enlarged veins through laparoscopy;
- clamping of veins in the small pelvis with special medical clips (clipping);
- crossectomy - vein ligation (prescribed if, in addition to the pelvic organs, the vessels of the lower extremities are affected).
During pregnancy, only symptomatic therapy of varicose veins of the small pelvis is possible. It is recommended to wear compression tights, take phlebotonics on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of the varicose veins of the perineum 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.
The system of physical activity for the treatment of varicose veins in a woman consists of exercises:
- "Bike". We lie on our backs, throw our hands behind our heads or place them along the body. Raising our legs, we perform circular movements with them, as if we were pedaling on a bicycle.
- "Birch". We sit face up on any hard, comfortable surface. Raise your legs up and smoothly start them behind your head. Supporting the lumbar region with your hands and putting your elbows on the floor, slowly straighten your legs, lifting the body up.
- "Scissors". The starting position is on the back. Raise the closed legs slightly above the floor level. We spread the lower limbs to the sides, return them back and repeat.
Why are varicose veins of the small pelvis dangerous? The following consequences of the disease are often recorded:
- inflammation of the uterus, its appendages;
- uterine bleeding;
- abnormalities in the work of the bladder;
- the formation of venous thrombosis (a small percentage).
In order for varicose veins in the small pelvis to disappear as soon as possible and in the future there is no recurrence of the pathology of the pelvic organs, it is worth adhering to simple preventive rules:
- perform gymnastic exercises daily;
- prevent constipation;
- observe a dietary regimen, in which plant fiber must be present;
- do not stay in one position for a long time;
- take a contrast shower of the perineum;
- so that varicose veins do not appear, it is better to wear exceptionally comfortable shoes and clothes.
Preventive measures aimed at reducing the risk of the onset and progression of varicose veins in the small pelvis are mainly reduced to the normalization of the lifestyle.