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What will varicose veins of the small pelvis say in women?

From the article you will learn the characteristics 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 genitalia.

varicose veins of the pelvis

general information

In the literature, varicose veins of the pelvis are also called "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 younger than 17 to 80% in perimenopausal women. Most often, pelvic vein pathology is diagnosed in the reproductive period in patients aged 25-45 years.

In the vast 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, VVMT treatment should be carried out not so much from the point of view of gynecology, but, above all, from the point of view of phlebology.

Pathological triggers

By varicose veins of the pelvic organs in women, doctors understand the change in the structure of the vascular walls characteristic of other types of disease - weakening followed by stretching and the creation of "pockets" within which the blood stagnates. Extremely rare are cases where only the vessels of the pelvic organs are affected. In about 80% of patients, with this form, there are signs of varicose veins of the inguinal veins, veins of the lower extremities.

The frequency of varicose veins of the small pelvis is most pronounced in women. This is due to anatomical and physiological characteristics, which indicates 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 of pregnancy;
  • periods of more active filling of veins with blood, including cyclic menstruation, during pregnancy, as well as during sex.

All these phenomena fall into the category of factors that cause varicose veins. And they are found exclusively in women. Most patients face varicose veins of the small pelvis during pregnancy, as there is a simultaneous layering of provoking factors. According to statistics, in men, varicose veins of the small pelvis are 7 times less common than in the fairer sex. They have a more diverse set of provocative factors:

  • hypodynamics - long-term maintenance of low physical activity;
  • increased physical activity, especially weightlifting;
  • obesity;
  • lack of enough fiber in the diet;
  • inflammatory processes in the organs of the genitourinary system;
  • sexual dysfunction or lucid refusal of sex.

Genetic predisposition can also lead to pathology of the plexuses located within 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 disease. The first changes in them can be noticed in adolescence during puberty.

The highest risk of developing inguinal varicose veins in women with pelvic vascular involvement was observed in patients with venous pathology in other parts of the body. In this case, we are talking about congenital vein weakness.

Etiopathogenesis

Proctologists believe that the following main reasons always contribute to the development of VVP: valvular insufficiency, venous obstruction and hormonal changes.

Pelvic venous congestion syndrome can develop due to congenital absence or insufficiency of venous valves, which was discovered by anatomical studies in the last century, and modern data confirm that.

It has also been found that in 50% of patients, varicose veins are of a genetic nature. FOXC2 was one of the first genes identified to play a key role in VVP development. Currently, a connection has been established between the development of the disease and gene mutations (TIE2, NOTCH3), thrombomodulin levels and growth factor β, which transforms type 2. These factors contribute to changes in the structure of the valve or venous wall - all leading to valve structure failure; varicose veins, which causes a change in valve function; to progressive reflux and finally 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 different types of collagen or a violation of the ratio between them, which leads to a decrease in venous 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 woman's uterus and the vasodilating effect of progesterone. This venous dilatation lasts for a month after delivery and can cause venous valve failure. In addition, during pregnancy, the mass of the uterus increases, there is a change in position, which causes stretching of the ovarian veins, followed by venous congestion.

Risk factors include endometriosis and other inflammatory diseases of the female reproductive system, estrogen therapy, unfavorable working conditions for pregnant women, which include heavy physical work 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 characteristics of the outflow from the small pelvic veins. 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 nut syndrome occurs. This is the so-called anterior, or true, nut syndrome, which has the greatest clinical significance. Posterior nut syndrome occurs in rare cases in patients with a retroaortic or annular arrangement of the distal left renal vein. Obstruction of the proximal venous trough causes an increase in pressure in the renal vein, leading to the formation of renoovarian reflux in the left ovarian vein with the development of chronic venous insufficiency of the pelvis.

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 more common in women. Currently, due to the introduction of radiation methods and endovascular imaging in practice, this pathology is being discovered more and more often.

Classification

Varicose veins are divided into the following forms:

  • Primary type of varicose veins: enlargement of the pelvic blood vessels. The reason is type 2 valvular insufficiency: acquired or congenital.
  • The secondary form of pelvic vein thickening is diagnosed exclusively in the presence of gynecological pathologies (endometriosis, neoplasms, polycystic).

Varicose veins of the pelvis gradually develop. There are several major stages in the development of the disease in medical practice. They will vary 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 vein diameter up to 5 mm. The left ovary has a pronounced expansion in the outer parts.
  • Second degree. This stage is characterized by the spread of pathology and damage to the left ovary. Veins in the uterus and right ovary can also be dilated. The diameter of the expansion reaches 10 mm.
  • Third degree. The diameter of the veins increases to 1 cm. Vein dilation is seen equally on the right and left ovaries. This phase is a consequence of pathological phenomena of gynecological nature.

It is also possible to classify the disease depending on the primary cause of its development. There is a primary stage, in which the dilation is caused by a malfunction of the venous valves, and a secondary stage, which is the result of chronic female diseases, inflammatory processes, or complications of an oncological nature. The degree of the disease can vary depending on the anatomical characteristics, which indicates the localization of the vascular disorder:

  • Intra-caste abundance.
  • Vulva and perineal.
  • Combined shapes.

Symptoms and clinical manifestations

In women, varicose veins of the pelvis are accompanied by severe but nonspecific symptoms. Often, the manifestations of this disease are considered signs of gynecological disorders. The main clinical symptoms of varicose veins in the groin in women with pelvic vascular involvement are:

pain in the lower abdomen with varicose veins of the small pelvis
  • Nonmenstrual pain in the lower abdomen. Their intensity depends on the stage of damage to the veins and the scope of the process. Grade 1 varicose veins of the pelvis are characterized by periodic, mild pain, which extends to the lower back. In the later stages it is felt in the abdomen, perineum and lower back, and is long and intense.
  • Abundant mucous discharge. The so-called leukorrhea does not have an unpleasant odor, it 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, the pain in women intensifies, until the onset of difficulty walking. During menstrual bleeding, it can become unbearable, spreading to the entire pelvic region, perineum, lower back, and even 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 dull pain. It can be seen at the end of intercourse. In addition, the disease is accompanied by increased anxiety, irritability and mood swings.
  • As with varicose veins of the pelvis in men, the female part of patients with such a diagnosis gradually loses interest in sex. The cause of dysfunction is constant discomfort and reduced production of sex hormones. In some cases, infertility can occur.

Instrumental diagnostics

The diagnosis and treatment of varicose veins is performed by a phlebologist, a vascular surgeon. Currently, the number of cases of VVP detection has increased due to new technologies. Patients with CPP are examined in several stages.

  • The first phase is a routine examination by a gynecologist: taking a history, manual examination, ultrasound examination of the pelvic organs (to exclude other pathology). Based on the results, an examination by a proctologist, urologist, neurologist and other related specialists is additionally prescribed.
  • If the diagnosis is not clear, but there is a suspicion of VVPT, in the second phase, an ultrasound angioscanning (USAS) of the pelvic vein is performed. This is a non-invasive, highly informative method of screening diagnostics, which is used in all women with suspected VVPT. If it was previously believed that it was sufficient to examine only the pelvic organs (examination of veins was considered difficult to access and optional), then at the present stage ultrasound of the pelvic veins is a mandatory examination procedure. With the help of this method, it is possible to determine the presence of varicose veins of the small pelvis by measuring the diameter, blood flow velocity in the veins, and preliminarily determine the leading pathogenetic mechanism - ovarian vein failure or venous obstruction. Also, this method is used for dynamic assessment of conservative and surgical treatment of VVPT.
  • The study is performed transvaginally and transabdominally. Parameter veins, groin-like plexuses, and uterine veins are visualized transvaginally. According to various authors, the diameter of blood vessels in these localizations ranges from 2. 0 to 5. 0 mm (on average 3. 9 ± 0. 5 mm), ie. not more than 5 mm, and the average diameter of the arched 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 to rule out thrombotic masses and extravasal compression. The length of the left renal vein is 6 to 10 mm, and the average width is 4 to 5 mm. Normally, the left renal vein at the point where it passes through 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 pretenotica. zone. In the case of venous stenosis on the background of pathological compression, there is a significant reduction in its diameter - by 3, 5-4 times and 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 obligatory 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. The sign of ovarian vein failure in USAS is considered to be larger than 5 mm in diameter in the presence of retrograde blood flow. For a complete examination, prevention of recurrence and correct treatment tactics, it is necessary to do an ultrasound of the veins of the lower extremities, perineum, vulva, inner thigh and gluteal region.
  • The development of medical technology has led to the use of new diagnostic methods. In the third phase, after the ultrasound verification of the diagnosis, the methods of radiation diagnostics are used to confirm it.
  • Pelvic phlebography with selective bilateral radiopaque ovaryography is one of the radiation invasive diagnostic methods performed only in a hospital setting. This method has long been considered the diagnostic "gold standard" for assessing dilatation and detecting valvular insufficiency in 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 inserted into one of the main veins (jugular, brachial or femoral) into the iliac, renal and ovarian veins. Thus it is possible to identify anatomical variants of ovarian vein structure, to determine the diameters of gonadal and pelvic veins.
  • Retrograde contrast of gonadal veins at the height of the Valsalva test serves as a pathognomonic angiographic sign of their valvular insufficiency with visualization of sharp expansion and curvature. This is the most accurate method for detecting May-Turner syndrome, postthrombophlebitic changes in the iliac and inferior vena cava.
  • Compression of the left renal vein reveals perirenal venous collaterals with retrograde blood flow to the gonadal veins, stagnation of contrast in the renal vein. The method measures the pressure gradient between the left renal and inferior vena cava. Normal is 1 mm Hg. Art. ; gradient equal to 2 mm Hg. Art. , may suggest light compression; with gradient>3 mm Hg. Art. can be diagnosed with aorto-mesenteric compression syndrome with hypertension in the left renal vein, and a gradient of >5 mm Hg. Art. it is considered a hemodynamically significant stenosis of the left renal vein. Determining the pressure gradient is an important element of the diagnosis, because, depending on its values, essentially different surgical interventions are planned on the veins of the small pelvis, which is very important in modern conditions. Currently, this study (with a normal pressure gradient) can be used for therapeutic purposes - for embolization of ovarian veins.
  • The next method of irradiation is emission computed tomography of the pelvic veins with in vitro labeled erythrocytes. It is characterized by the deposition of marked erythrocytes in the pelvic veins and visualization of the gonadal veins, allows the identification of varicose plexuses of the pelvis and dilated ovarian veins in different positions, the degree of venous congestion of the pelvis, blood reflux from the pelvic vein to the saphenous veins of the legs and perineum. Normally, the ovarian veins are not contrasting, the accumulation of radiopharmaceuticals in the venous plexuses is not observed. For an objective assessment of the degree of venous congestion of the pelvis, the coefficient of venous congestion of the pelvis is calculated. But this method also has disadvantages: invasiveness, relatively low spatial resolution, inability to accurately determine the diameter of the veins, so it is not currently used so often in clinics.
  • Video laparoscopic examination is a valuable tool in assessing the undiagnosed. In combination with other methods, it can help determine the cause of pain and prescribe the correct treatment. In varicose veins of the small pelvis in the area of the ovaries, along the round and wide ligaments of the uterus, the veins can be visualized in the form of cyanotic, dilated vessels of a thinned and tense wall. The application of this method is significantly limited by the following factors: the presence of retroperitoneal adipose tissue, the ability to assess varicose veins only in a limited area and the inability to determine reflux through the veins. Currently, the use of this method is diagnostically justified in cases of suspected multifocal pain. Laparoscopy allows visualization of the cause of CPP, for example, foci of endometriosis or adhesions, in 66% of cases.

Characteristics of therapy

For complete treatment of varicose veins of the small pelvis, a woman must follow all the recommendations of the doctor and also change her lifestyle. First of all, you must pay attention to the loads, if they are too high, they must be reduced, if the patient leads an excessively sedentary lifestyle, it is necessary to do sports, walk more often, etc.

Patients with varicose veins are recommended to adjust their diet, consume as little fast 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 disease progression and for medical purposes, doctors prescribe wearing compression underwear for patients with varicose veins.

Medications

ERCT therapy involves several important points:

  • release from the reverse flow of venous blood;
  • alleviation of disease symptoms;
  • stabilization of vascular tone;
  • improved blood circulation in tissues.

Preparations for varicose veins should be taken in courses. The rest of the drugs, which have the role of painkillers, should be taken only during a painful attack. For effective therapy, the doctor often prescribes the following medications:

  • phleboprotectors;
  • enzyme preparations;
  • drugs that alleviate inflammatory processes with varicose veins;
  • tablets to improve blood circulation.

Surgical treatment

It is worth acknowledging that conservative treatment methods give really visible results mainly in the initial stages of varicose veins. At the same time, the problem can be substantially solved, and the disease can be completely eliminated only with surgery. In modern medicine there are many variations of surgical treatment of varicose veins, consider the most common and most effective types of surgery:

  • ovarian embolization;
  • sclerotherapy;
  • uterine ligament plastic;
  • removal of varicose veins by laparoscopy;
  • constriction of veins in a small pelvis with special medical clips (clipping);
  • crossectomy - ligation of a vein (prescribed if, in addition to the pelvic organs, the veins of the lower extremities are also affected).

During pregnancy, only symptomatic therapy of varicose veins of the pelvis is possible. We recommend wearing compression stockings, taking phlebotonics as recommended by a vascular surgeon. Phlebosclerosis of varicose veins of the perineum can be reported in the II-III trimester. If there is a high risk of bleeding during spontaneous delivery due to varicose veins, the choice is in favor of operative delivery.

Physiotherapy

The system of physical activity for the treatment of varicose veins in women consists of exercises:

  • "Bicycle". We lie on our backs, throw our arms behind our heads, or place them next to our bodies. Raising our legs, we perform circular movements with them, as if we were pedaling a bicycle.
  • "Birch. "We sit face up on any hard, comfortable surface. Lift your legs and move them slightly behind your head. Supporting the lumbar region with your hands and placing your elbows on the floor, slowly straighten your legs, lifting your body upwards.
  • "Scissors. "The starting position is on the back. Raise your closed legs slightly above floor level. Spread the lower limbs to the side, put them back and repeat.

Possible complications

Why are varicose veins of the pelvis dangerous? The following consequences of the disease are often recorded:

  • inflammation of the uterus, its appendages;
  • uterine bleeding;
  • bladder abnormalities;
  • formation of venous thrombosis (small percentage).

Prophylaxis

In order for the varicose veins in the small pelvis to disappear as soon as possible and for the pathology of the pelvic organs not to recur in the future, it is worth following simple preventive rules:

  • perform gymnastic exercises daily;
  • prevent constipation;
  • adhere to a diet in which plant fiber must be present;
  • do not stay in one position for long;
  • take a contrast shower of the perineum;
  • so that varicose veins do not appear, it is better to wear extremely comfortable shoes and clothes.

Preventive measures aimed at reducing the risk of occurrence and progression of varicose veins in the small pelvis are mainly reduced to the normalization of lifestyle.