What does the dilated veins of the female pelvis indicate?

From this article, you will learn about the characteristics of small pelvic varicose veins in women-this is the deformation of the veins in the pelvic area, and the blood flow to the internal and external reproductive organs is impaired.

Small pelvic varicose veins

General information

In the literature, small pelvic varicose veins are also called "pelvic congestion syndrome", "female varicocele", "chronic pelvic pain syndrome". The prevalence of small pelvic varicose veins is proportional to age: from 19. 4% in girls under 17 to 80% in perimenopausal women. In most cases, the pathology of the pelvic veins is diagnosed during the reproductive period of patients in the 25-45 age group.

In most cases (80%), varicose veins affect the ovarian veins, and it is extremely rare (1%) to observe the veins of the broad ligament of the uterus. According to modern medical methods, the treatment of VVMT should not be done from the perspective of gynecology, but first from the perspective of phlebology.

Pathological trigger

Under the varicose veins of the female pelvic organs, doctors learned that the structure of the blood vessel wall that is characteristic of other types of diseases has changed-weakened, and then stretched to form a "pocket" in which blood stagnates. It is extremely rare that only the blood vessels of the pelvic organs are involved. In about 80% of patients, in addition to this form, there are signs of varicose veins in the inguinal veins and lower limbs.

The incidence of small pelvic varicose veins is most obvious in women. This is due to anatomical and physiological characteristics that indicate a tendency to weaken the vein wall:

  • Hormonal fluctuations, including fluctuations related to the menstrual cycle and pregnancy;
  • Increased pressure in the small pelvis, which is a typical feature of pregnancy;
  • Periods when the veins are full of blood, including periodic menstruation, pregnancy, and sexual life.

All these phenomena belong to the category of factors that cause varicose veins. They only exist in women. Patients with small pelvic varicose veins are the most common during pregnancy, because there are multiple predisposing factors at the same time. According to statistics, the incidence of small pelvic varices in men is 7 times that of whites. They have more different stimuli:

  • Physical decline-maintain low physical activity for a long time;
  • Increase physical activity, especially weightlifting;
  • obesity;
  • Lack of enough fiber in the diet;
  • Inflammatory processes in the organs of the genitourinary system;
  • Sexual dysfunction or conscious refusal to have sex.

Genetic predispositions may also cause lesions in the nerve plexus located in the small pelvis. According to statistics, varicose veins of the perineum and pelvic organs most often occur in women whose relatives have this disease. Their first changes can be observed during adolescence during adolescence.

Among patients with venous disease in other parts of the body, women with pelvic vascular involvement have been observed to have the greatest risk of developing inguinal varicose veins. In this case, we are talking about congenital venous weakness.

Pathogenesis

Proctologists believe that the following main reasons always lead to the occurrence of VVP: valve insufficiency, venous obstruction and hormonal changes.

The occurrence of pelvic venous congestion syndrome is due to congenital venous valve loss or insufficiency. Anatomical studies in the last century have revealed this, and modern data have also confirmed this.

It was also found that in 50% of patients, varicose veins are hereditary. FOXC2 is one of the first genes discovered to play a key role in the development of VVP. At present, the relationship between the development of the disease and gene mutations (TIE2, NOTCH3), thrombomodulin levels and type 2 transforming growth factor β has been determined. These factors lead to changes in the valve itself or the structure of the vein wall-all of which will lead to the failure of the valve structure; the expansion of the veins leads to changes in valve function; progressive regurgitation, which eventually leads to varicose veins.

Dysplasia of connective tissue can play an important role in the development of the disease. Its morphological basis is that the content of various types of collagen decreases or violates 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 is especially noticeable during pregnancy. In pregnant women, due to the mechanical compression of the pregnant uterus on the pelvic blood vessels and the vasodilator effect of progesterone, the volume of the pelvic vein increases by 60%. This venous dilation can last for a month after delivery and may lead to venous valve failure. In addition, during pregnancy, the quality of the uterus will increase and the position will change, which will cause the ovarian veins to stretch and then venous congestion.

Risk factors also include endometriosis and other inflammatory diseases of the female reproductive system, estrogen therapy, poor working conditions for pregnant women, including hard physical work and prolonged forced postures (sitting or standing) during the working day.

The anatomical features that flow from the small pelvic veins also promote the formation of small pelvic varicose veins. The diameter of the ovarian vein is usually 3-4 mm. The elongated ovarian vein on the left flows into the left renal vein, and the right into the inferior vena cava. Under normal circumstances, 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 is 51±25° in adults, 45. 8±18. 2° in children, and 45. 3±21. 6° in girls. When the angle is reduced from 39. 3 ± 4. 3 ° to 14. 5 °, aortic mesenteric compression or nutcracker syndrome may occur. This is the so-called anterior or true nutcracker syndrome and has the greatest clinical significance. Posterior nutcracker syndrome rarely occurs in patients with aortic or circular arrangement of the distal left renal vein. The obstruction of the proximal venous bed leads to an increase in renal vein pressure, leading to renal venous reflux in the left ovarian vein, which leads to chronic pelvic venous insufficiency.

May-Turner syndrome-the right common iliac artery compresses the left common iliac vein-is also one of the causes of pelvic varices. It occurs in no more than 3% of cases and is more common in women. At present, due to the introduction of radiation and intravascular imaging methods into practice, this pathology is increasingly being detected.

Classification

Varicose veins are divided into the following forms:

  • The main types of varicose veins: increased pelvic blood vessels. The reason is two types of valve insufficiency: acquired or congenital.
  • Secondary forms of thickening of the pelvic veins are only diagnosed in the presence of gynecological diseases (endometriosis, tumors, polycystic).

Varicose veins of the pelvis develop gradually. In medical practice, there are several main stages in the development of diseases. They will vary based on the presence of complications and the spread of the disease:

  • The first level. The structural changes of the ovarian vein valve may be due to genetic reasons or acquired. The disease is characterized by an increase in vein diameter to 5 mm. The left ovary has obvious expansion on the outside.
  • The second degree. This degree is characterized by pathological spread and damage to the left ovary. The veins of the uterus and right ovary may also dilate. The expansion diameter reaches 10mm.
  • Three degrees. The diameter of the vein increases to 1 cm. The venous dilation observed on the right and left ovaries is equal. This stage is due to pathological phenomena of gynecological nature.

It is also possible to classify diseases according to the main causes of their development. There is one level, where the expansion is caused by the functional defect of the venous valve, and the second level is caused by chronic female diseases, inflammatory processes, or complications of a tumor nature. The extent of the disease can vary based on anatomical features, which indicates the location of the vascular disease:

  • Too many internal castes.
  • Vulva and perineum.
  • Combination.

Symptoms and clinical manifestations

In women, pelvic varicose veins are accompanied by severe but non-specific symptoms. Usually, the manifestations of this disease are considered to be signs of gynecological diseases. The main clinical symptoms of inguinal varicose veins in women with pelvic vascular involvement are:

Pain in the lower abdomen, small pelvic varicose veins
  • Non-menstrual pain in the lower abdomen. Their strength depends on the stage of vein damage and the extent of the process. For 1 degree varicose veins of the small pelvis, periodic mild pain extending to the lower back is characteristic. Later, it can be felt on the abdomen, perineum and waist, and it is long and strong.
  • A large amount of mucus is discharged. The so-called leucorrhea does not have an unpleasant smell and does not change color, which indicates an infection. The discharge volume increases in the second phase of the cycle.
  • The symptoms of premenstrual syndrome and dysmenorrhea are aggravated. Even before the start of menstruation, women’s pain will increase and they may even have difficulty walking. During menstrual bleeding, it becomes unbearable and spreads to the entire pelvic area, perineum, lower back, and even thighs.
  • Another characteristic of women with varicose veins in the groin is discomfort during sexual intercourse. It is felt in the vulva and vagina and is characterized by dull pain. It can be observed at the end of sexual intercourse. In addition, the disease is accompanied by an increase in anxiety, irritability and mood swings.
  • As with male small pelvic varicose veins, the female part of female patients gradually loses interest in sex. The cause of the dysfunction is constant discomfort and decreased production of sex hormones. In some cases, infertility may occur.

Instrument diagnosis

Diagnosis and treatment of varicose veins are performed by phlebologists and vascular surgeons. At present, due to the application of new technologies, the number of VVP detection cases has increased. CPP patients are examined in several stages.

  • The first stage is a routine examination by a gynecologist: medical history, physical examination, and ultrasound examination of pelvic organs (excluding other pathologies). Based on the results, additional examinations will be performed by proctologists, urologists, neurologists and other relevant experts.
  • If the diagnosis is not clear, but VVPT is suspected, pelvic vein ultrasound vascular scan (USAS) is performed in the second stage. This is a non-invasive, informative screening and diagnosis method, suitable for all women suspected of VVPT. If it was previously considered sufficient to examine only the pelvic organs (vein examination was considered difficult and optional), then at this stage, pelvic vein ultrasound examination is a mandatory examination procedure. With this method, it is possible to determine the presence of small pelvic varicose veins by measuring the diameter of the vein and the blood flow velocity, and to initially find out the main pathogenesis-the failure of varicose veins. Ovarian vein or vein obstruction. In addition, this method is used for dynamic assessment of conservative and surgical treatment of VVPT.
  • The study was conducted transvaginally and transabdomenally. Parauterine veins, inguinal plexus and uterine veins can be observed through the vagina. According to different authors, the diameter of the vessels named and located ranges from 2. 0 to 5. 0 mm (average 3. 9 ± 0. 5 mm), that is, no more than 5 mm, and the average diameter of the arcuate vein is 1. 1 ± 0. 4 mm. Veins larger than 5 mm in diameter are considered to be dilated. Examine the inferior vena cava, iliac vein, left renal vein and ovarian vein through the abdomen to rule out thrombotic masses and extravascular compression. The left renal vein is 6-10mm long, with an average width of 4-5mm. Under normal circumstances, the left renal vein passing through the aorta is slightly flattened, but its transverse diameter is reduced by 2-2. 5 times, blood flow is not significantly accelerated, normal outflow is ensured, and the pressure in the anterior bundle is not increased. Area. In the case of venous stenosis under the background of pathological compression, its diameter is significantly reduced-3. 5-4 times, and blood flow is accelerated-more than 100 cm / s. The sensitivity and specificity of this method are 78% and 100%, respectively.
  • The examination of the ovarian veins is included in the mandatory examination of the pelvic veins. They are located on the anterior abdominal wall, along the rectus abdominis muscle, slightly outside the iliac veins and arteries. In USAS, signs of ovarian vein failure are considered to be more than 5 mm in diameter and retrograde blood flow. In order to comprehensively check, prevent recurrence and correct treatment strategies, it is necessary to perform ultrasound examination of the veins in the lower limbs, perineum, vulva, inner thigh and buttocks area.
  • The development of medical technology has led to the use of new diagnostic methods. In the third stage, after the diagnosis is confirmed by ultrasound diagnosis, the diagnosis is confirmed by radiological diagnosis.
  • Pelvic venography with selective bilateral radiopaque ovarian radiography is a radio-invasive diagnostic method that is only performed in a hospital environment. This method has long been regarded as the diagnostic "gold standard" for evaluating dilation and detecting pelvic venous valve insufficiency. The essence of this method is to introduce the contrast agent into the iliac, renal and ovarian veins through a catheter installed in a major vein (jugular vein, brachial vein or femoral vein) under the control of an X-ray device. Therefore, the anatomical variation of the ovarian vein structure can be identified to determine the diameter of the gonadal and pelvic veins.
  • At the height of the Valsalva test, the retrograde contrast of the gonadal veins, as a characteristic angiographic sign of valve insufficiency, showed sharp dilation and curvature, respectively. This is the most accurate way to detect changes in May-Turner syndrome, ilium and inferior vena cava thrombophlebitis.
  • When the left renal vein is compressed, the collateral branches of the perrenal vein flow retrogradely into the gonadal vein, confirming the retention of contrast agent in the renal vein. This method measures the pressure gradient between the left kidney and the inferior vena cava. Usually 1 mmHg. Art . ; The gradient is equal to 2 mmHg. Art, may imply slight compression; gradient >3 mm Hg. Art. Left renal vein hypertension, gradient >5 mm Hg can diagnose aortic-mesenteric compression syndrome. Art. It is believed that the hemodynamics of the left renal vein is significantly narrowed. The determination of the pressure gradient is an important factor in the diagnosis, because according to its value, essentially different surgical interventions are planned for the small pelvic veins, which is very important under modern conditions. Currently, this study (with a normal pressure gradient) can be used for therapeutic purposes-for ovarian vein thrombosis.
  • The next radiation method is to use the red blood cells labeled outside the body to perform emission computed tomography of the pelvic vein. It is characterized by the deposition of marked red blood cells in the pelvic veins and the visualization of gonadal veins, which can identify small pelvic varicose veins and dilated ovarian veins in different positions, the degree of congestion of the pelvic veins, and the recession of blood flowing back into the pelvic veins into the legs and perineum. vein. Normally, without comparing the ovarian veins, no accumulation of radiopharmaceuticals in the venous plexus was observed. In order to objectively assess the degree of venous congestion in the small pelvis, calculate the pelvic venous congestion coefficient. However, this method also has disadvantages: it is very invasive, has low spatial resolution, and cannot accurately determine the diameter of the vein. Therefore, it is not widely used in clinical practice.
  • Video laparoscopy is a valuable tool for evaluating undiagnosed patients. Combined with other methods, it can help determine the cause of pain and prescribe the correct treatment. Small pelvic varicose veins in the ovarian area, along the round ligament and broad ligament of the uterus, you can see cyanotic, dilated blood vessels, thinning and tense walls. The use of this method is significantly limited by the following factors: the presence of retroperitoneal fat tissue, the possibility of assessing varicose veins only in a limited area, and the impossibility of determining reflux through veins. At present, in the case of suspected multifocal pain, the use of this method is diagnostically reasonable. Laparoscopy can show the cause of CPP in 66% of cases, such as endometriosis or adhesions.

Treatment characteristics

For the comprehensive treatment of small pelvic varicose veins, women must follow all the doctor’s advice and change their lifestyles at the same time. First of all, pay attention to the load. If the load is too high, the load must be reduced. If the patient is living a sedentary lifestyle, he should exercise more and take more walks.

It is strongly recommended that patients with varicose veins adjust their diet and eat as little junk food as possible (fried, smoked, a lot of sweets, salty, etc. ), alcohol, and caffeine. It is best to give preference to vegetables and fruits, dairy products, and grains.

In addition, in order to prevent the progression of the disease and for medical purposes, doctors recommend that patients with varicose veins wear pressure underwear.

drug

The treatment of ERCT means several points:

  • Get rid of the reflux of venous blood;
  • Relieve the symptoms of the disease;
  • Stabilize blood vessel tension;
  • Improve blood circulation in the tissues.

The preparation for varicose veins should be done in the course. The rest of the medicine that acts as an analgesic can only be taken during the onset of pain. For effective treatment, doctors usually prescribe the following drugs:

  • Intravenous protective agent;
  • Enzyme;
  • Drugs to relieve the inflammatory process of varicose veins;
  • Pills to improve blood circulation.

operation treatment

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

  • Ovarian vein thrombosis;
  • Sclerotherapy
  • Plastic of the uterine ligament;
  • Resection of enlarged veins through laparoscopy;
  • Clamp the veins in the small pelvis with special medical clips (clamps);
  • Cross resection-vein ligation (if the blood vessels of the lower extremities are also affected in addition to the pelvic organs, this method is prescribed).

During pregnancy, only symptomatic treatment of small pelvic varicose veins is possible. We recommend wearing tight pants and giving intravenous injections under the advice of a vascular surgeon. Within three months of II-III, the perineal varicose veins can be hardened. If the risk of bleeding during natural delivery is high due to varicose veins, surgical delivery is chosen.

physiotherapy

The physical activity system used to treat varicose veins in women includes the following exercises:

  • "bike". We lie on our backs and put our hands behind our heads or on our bodies. Lift up our legs and we use them in circular motions, just like we are riding a bicycle.
  • "birch". We sit face-up on any hard, comfortable surface. Lift your legs and gently place them behind your head. Support your waist with your hands and place your elbows on the floor. Slowly straighten your legs and lift your body up.
  • "Scissors". The starting position is behind. Raise the closed leg slightly above the floor level. We spread the lower limbs to both sides, put them back in place and repeat.

Possible complications

Why are small pelvic varicose veins dangerous? The following consequences of the disease are usually recorded:

  • Inflammation of the uterus, its appendages;
  • uterine bleeding;
  • Abnormal bladder work;
  • Formation of venous thrombosis (a small part).

prevention

In order to make the varicose veins of the small pelvis disappear as soon as possible, and the pathology of the pelvic organs will not recur in the future, it is still necessary to observe the simple precautionary principles:

  • Do gymnastics exercises every day;
  • Prevent constipation;
  • Follow the diet plan, where plant fiber must be present;
  • Don't stay in one position for a long time;
  • Contrast showering on the perineum;
  • In order to avoid varicose veins, it is best to wear particularly comfortable shoes and clothes.

Preventive measures aimed at reducing the risk of occurrence and development of small pelvic varicose veins are mainly to reduce the normalization of lifestyle.