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Pelvis » Female Pelvis (Gynecology)
Pelvic varices
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Presentation A 40 year old woman presents with vague pelvic pain of several months duration. She has regular menses and has had four normal pregnancies. A transvaginal ultrasound was performed.
 
 
 
Caption: Transvaginal image of the uterus.
Description: The uterus appears bulky and shows prominent myometrial vasculature.
 
 
 
Caption: Transvaginal scan of the uterus.
Description: The bulky uterus is noted again, with a hypoechoic mass seen posteriorly- this is suggestive of a fibroid.
 
 
 
Caption: Sagittal scan of the right adnexa.
Description: Multiple, tubular serpigineous structures are seen coursing along the para-uterine region. These structures seem to be originating from the pelvic side walls [seen as bright echogenic lines].
 
 
 
Caption: Transvaginal image of the right adnexa.
Description: The tubular serpigineous hypodensities are noted again along the para-uterine region.
 
 
 
Caption: Color Doppler image on the right side.
Description: The tubular structures on the right side completely fill with color, suggesting that these are abnormally dilated and tortuous vessels.
 
 
 
Caption: Power Doppler image of the left adnexa.
Description: Multiple, dilated and tortuous vessels are seen in the left adnexa as well.
 
 
 
Caption: Sagittal view of the left adnexa.
Description: The tubular structures are noted in the left adnexa as well.
 
Differential Diagnosis Pelvic varices with an intramural uterine fibroid.
 
Final Diagnosis Pelvic varices with an intramural uterine fibroid.
 
Discussion

Pelvic varices in women consist of tortuous and dilated parauterine veins [in the broad ligament] and ovarian veins. They are often bilateral. Concomitant paravaginal, pelvic sidewall and internal iliac varicosities may also be present. Occasionally, pelvic varices may communicate with vulvar and lower extremity varices. There may also be associated ovarian vein reflux.

Pelvic varices may occur due to various causes, a few of which include thin-walled and unsupported structure of the veins, the presence of few valves, multi-parous state, gravity and prolonged upright position. Overall they mostly represent a late complication of pregnancy.

Classification- Pelvic varices may be
 1.Primary –
  • Occurs de novo, without any underlying pathology.
  •They are responsible for causing the pelvic congestion syndrome and cause chronic  pelvic pain. 
 2.Secondary –
  • Occurs due to some underlying organic pathologies such as endometriosis, pelvic  inflammatory disease, leiomyoma, large pelvic tumors.
  • Are usually painless.

Clinical presentation – Most of the patients are in the reproductive age group; they may be completely asymptomatic, present with non-specific chronic pelvic pain [15-20%], or present with the ‘pelvic congestion syndrome’, characterized by symptoms of congestive dysmennorhea, dyspareunia or urinary complaints. Pregnancy and postpartum period may aggravate the condition. Thrombosed varicose veins especially in the round ligament may simulate an inguinal hernia.

Associations – Pelvic varices may be associated with ovarian, vaginal and vulvar varices. Secondary varices are associated with pathologies described above.

Imaging appearance – Ultrasound, CT and MRI all have been used to diagnose pelvic varices non-invasively. The gold standard has been venography, but is now ultrasound.
Ultrasound features:
• The pelvic varices may be seen as long, tubular, hypoechoic tortuous structures in the adnexae.
• These may extend laterally in the broad ligament upto the pelvic side wall and inferiorly may extend into the paravaginal venous plexus.
• If thrombosed, echogenic material may be seen within these tortuous structures.
• On color Doppler imaging, these varices completely fill with color.

Differential diagnosis – the following may be considered:
1. Cystic adnexal masses – the absence of color within the masses differentiates them from varices. 

Management- Transcatheter embolization involving venous embolization or ovarian vein excision and / or sclerotherapy of the involved veins after control of the intrapelvic reflux, are the treatment options available.

 
Case References

1. Haag T, Manhes H. Chronic varicose pelvic veins. J Mal Vasc. 1999 Oct; 24(4):267-74.
2. Hodgson TJ, et al. Case report: the ultrasound and Doppler appearances of pelvic varices. Clin Radiol. 1991 Sep; 44(3):208-9.
3. Coakley FV, et al. CT and MRI of pelvic varices in women. J Comput Assist Tomogr. 1999 May-Jun; 23(3):429-34.
4. Jvarsheishvili L, et al. Transvaginal ultrasound examination of pelvic varices in women with chronic pelvic pain (SE 07) C-0344 .www.ecr.org
5. Scultetus AH, et al. The pelvic venous syndromes: analysis of our experience with 57 patients. J Vasc Surg. 2002 Nov; 36(5):881-8.
6. Al-Qudah MS. Postpartum pain due to thrombosed varicose veins of the round ligament of the uterus. Postgrad Med J. 1993 Oct; 69(816):820-1.
7. Park SJ, Lim JW, et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR. 2004 Mar; 182(3):683-8.

 
Follow Up

This patient was operated upon and is currently doing well.

 
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