Treatment of Vaginal Varicosities

Background: Vulvar varicosities affect 18 to 22% of pregnant women. During pregnancy the treatment of choice is conservative, however they remain in 4 to 8% of women after pregnancy and can lead to dyspareunia and vulvodynia, dysuria, pelvic and lower limb heaviness and pain. Vulvar varicosities is a complex disease involving three routes for the pelvic drainage such as the femoral vein, internal iliac vein and Inferior Vena Cava and their numerous connection and are commonly associated with pelvic congestion syndrome. In Pregnant women this is due to the increase of venous flow, venous compression by the uterus and hormonal changes. In nulipare it can be triggered by compression such as the Nut-Cracker Syndrome, Cockett syndrome, venous malformation and thrombosis/obstruction. A correct diagnosis is essential to provide the best treatment which consist in different techniques such as endovascular embolization, surgical ligation/ phlebectomy of the contributing veins, sclerotherapy and micronized purified flavonoid fraction (MPFF). A Multidisciplinary approach involving gynecologist, angiologist, interventional radiologist and vascular surgeons is mandatory.

Educational Points Methods: Vulvar varicosities can be mostly diagnosed at clinical examination. Duplex ultrasound of the vein of the pelvis and lower extremities can identify any retrograde flow and venous incompetency and provide information of the venous anatomy of the pelvis. MRV venogram is provided to assess any pelvic flow obstruction or reflux origin and exclude other pelvic pain of gynecological origin such as endometriosis, retroverse uterus or Master and Allen Syndrome. In Our Vascular Department we assess clinically the patient and their symptoms and exclude any other gynecological causes prior to further investigations with Ultrasound and MR venogram. We will then provide the patient with the best treatment which consist in one or all of the following such as venous stenting, pelvic embolization and sclerotherapy of the vaginal varicosities.

Conclusion: Diagnosis and treatment of vulvar varicosities has evolved in recent years however there is a lack of awareness and management approach due to the complexity of its treatment and the anatomy of the pelvis. The treatment of pelvic varicosities require a clear hemodynamic strategy based on correcting the reflux without compromising its drainage. A tailored approach to women suffering from vulvar insufficiency and its symptoms with the correct diagnostic tools and treatment can improve their quality of life.

Publication History

Article published online:
02 April 2024