Pelvic varicose vein

The evidence that pelvic varicose veins cause pain is indirect. Pelvic varicosities are more frequently seen in women with pelvic pain than in asymptomatic patients. In one study of transuterine venography, 91% of patients with chronic pelvic pain had evidence of pelvic varicosities compared with 11% of control patients [8]. When intravenous dihydro-ergotamine (a vasoconstrictor), is administered to women during an acute attack of pelvic pain there is both a decrease of pelvic venous diameter and a significant reduction in pain [9]. 

Although imaging can demonstrate pelvic varicose veins [24], direct visualization of tortuous and... 

Pelvic congestion is a complex subject. When considering the pathophysiology, two components must be considered (Fig. 11.1) gonadal vein reflux, which is the commonest cause of pelvic varicosities, and the pelvic varicosities themselves, whidi are felt to be the principle cause of pain in pelvic congestion syndrome. Each maybe seen without the other, and both can be present in asymptomatic patients. 

The association between varicose veins in the pelvis and pelvic pain in women has been known since the description of tubo-ovarian varicocele by Richet in 1857 [1]. However, it was not until 1976 that the phrase pelvic congestion syndrome was coined by Hobbs [2] to describe a syndrome of chronic pelvic pain and heaviness due to pelvic varicosities. The pelvic varicosities are almost always secondary to reversed flow in the ovarian vein, in essence a female... 

Fig. 11.1. Pelvic congestion syndrome. Selective injection of the left ovarian vein reveals retrograde flow in a dilated left ovarian vein and results in opaciflcation of an extensive network of pelvic varicosities...

Pelvic veins are uniquely predisposed to become dilated, even without pregnancy. Many pelvic veins are devoid of valves and have weak attachments between the adventitia and supporting connective tissue [12]. Although this is different from veins elsewhere in the body the histology of pelvic varicosities is similar to that of varicose veins elsewhere, including fibrosis of the tunica intima and media, muscular hypertrophy and proliferation of capillary endothelium. 

All patients with chronic pelvic pain should have the benefit of clinical evaluation and shared care by a physician with expertise in chronic pelvic pain. A laparoscopy and pelvic ultrasound should be performed prior to radiologic interventions. Their role is to exclude other diagnoses, not to make the diagnosis of pelvic congestion. If the clinical presentation is recurrent lower extremity varicose veins or... 

The same multipurpose shape catheter is then directed into the right ovarian vein. A right ovarian venogram and, if needed, embolization are performed in the same fashion as described for the left. If the ovarian venograms are negative, then bilateral internal iliac venograms are performed as rarely isolated pudendal vein reflux will cause symptomatic pelvic varicosities (Figs. 11.7a,b). We do not routinely study the internal iliac veins if ovarian vein reflux is found however, other interventionists do this routinely [34]. 

Fig. 11.7a,b. Internal iliac venography, a Normal study. Selective injection of contrast in right internal iliac vein demonstrates prominent pelvic anastomotic connections, but no varicosities are seen, b Pelvic varicosity in internal iliac venous system. There is bulbous dilation of the left pudendal vein. On delayed images sluggish drainage of contrast was seen... 

Chidekel N (1968) Female pelvic veins demonstrated by selective renal phlebography with particular reference to pelvic varicosities. Acta Radiol 193 1-20... 

Rundqvist F,Sandhold IE,et al. (1984) Treatment of pelvic varicosities causing lower abdominal pain with extraperi-toneal resection of the left ovarian vein. Ann Chir Gynaecol 2 946-951... 

Circulatory system—maternal blood volvune rises about 30 percent and cardiac output rises to 30-40 percent above normal until about 27 weeks. The pregnant uterus presses on the large pelvic blood vessels, reducing venous return and causing edema of the feet, along with varicose veins and... 

Ovarian varicosities are more frequent after pregnancy [10] due to hemodynamic and physiologic factors which result in pelvic venous hypertension during pregnancy. The capacity of the ovarian veins... 

Fig. 11.10a,b. Labial varicosities, a Left ovarian vein injection. There are multiple pelvic sidewall varicosities and faint opacification of labial varices. Very delayed images are often required, b Left labial venogram using butterfly needle... 

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