What will the dilated veins in the small pelvis tell about in women?

In the vast majority of cases (80%), varicose transformation affects the ovarian veins and is extremely rare (1%) observed in the veins of the uterine's broad ligaments. According to modern medical approaches, the treatment of VVMT should be performed not so much from a gynecological point of view, but first and foremost from a phlebological point of view.

Pathology triggers

By varicose veins in the pelvic organs in women, doctors understand a change in the structure of the vessel walls that is characteristic of other types of the disease - weakening followed by stretching and the formation of "pockets" inside which the blood stagnates. Cases where only the vessels in the pelvic organs are affected are extremely rare. In about 80% of patients, along with this form, there are signs of varicose veins in the groin veins, vessels in the lower extremities.

The occurrence of varicose veins in the small pelvis is most pronounced in women. This is due to anatomical and physiological features, suggesting 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 the veins with blood, including cyclic menstrual periods, during pregnancy as well as during sex.

All of these phenomena belong to the category of factors that provoke varicose veins. And they are found exclusively in women. The largest number of patients face varicose veins in the small pelvis during pregnancy, as there is a simultaneous stratification of provocative factors. According to statistics, among men, varicose veins in the small pelvis are 7 times less common than among the fairer sex. They have a more diverse set of provocative factors:

• hypodynamics - long-term preservation of low physical activity;
• increased physical activity, especially pulling weights;
• obesity;
• lack of adequate fiber in the diet;
• inflammatory processes in the organs of the genitourinary system;
• sexual dysfunction or clear refusal to have sex.

A genetic predisposition can also lead to the pathology of the plexuses located inside the small pelvis. According to statistics, varicose veins in the perineum and pelvic organs are most often diagnosed in women whose relatives suffered from this disorder. The first changes in them can be observed in adolescence during puberty.

The greatest risk of developing groin ulcers in women with involvement of the pelvic vessels is observed in patients with venous pathology in other parts of the body. In this case, we are talking about congenital weakness in the veins.

Ethiopathogenesis

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

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

It was also found that in 50% of patients, varicose veins are of a genetic nature. FOXC2 was one of the first identified genes to play a key role in the development of VVP. Currently, the relationship between the development of the disease and gene mutations (TIE2, NOTCH3), the level of thrombomodulin and type 2 transforming growth factor β has been determined. These factors contribute to a change in the structure of the valve itself or the vein wall - all this leads to failure of the valve structure; dilation of the vein, causing a change in valve function; to progressive reflux and ultimately to varicose veins.

An important role in the development of the disease can be played by connective tissue dysplasia, whose morphological basis is a decrease in the content of different types of collagen or a violation of the relationship between them, leading to a decrease in venous strength.

The incidence of VVP is directly proportional to the amount of hormonal changes that are particularly pronounced during pregnancy. In pregnant women, the capacity of the pelvic veins is increased by 60% due to the mechanical compression of the pelvic vessels from the pregnant uterus and the vasodilating effect of progesterone. This venous dilation persists for one month after birth and can cause venous valve failure. In addition, the mass of the uterus increases during pregnancy, its position changes occur, causing stretching of the ovarian veins followed by venous congestion.

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

The formation of varicose veins in the small pelvis is also facilitated by the anatomical features of the outflow from the veins in the small pelvis. The diameter of the ovarian veins is usually 3-4 mm. The long and thin ovarian veins on the left flow into the left renal veins and to the right into the inferior vena cava. Usually, the left renal vein is located in front of the aorta and behind the upper mesenteric artery. The physiological angle between the aorta and the upper mesenteric artery is approx. 90 °.

This normal anatomical position prevents compression of the left renal vein. On average, the angle between the aorta and the upper mesenteric artery in adults is 51 ± 25 °, in children - 45, 8 ± 18, 2 ° in boys and 45, 3 ± 21, 6 ° in girls. In case of a decrease in the angle from 39, 3 ± 4, 3 ° to 14, 5 °, aorto-mesenteric compression or nutcracker syndrome occurs. This is the so-called anterior, or true, nutcracker syndrome, which has the greatest clinical significance. Posterior nutcracker syndrome occurs in rare cases in patients with a retroaorta or annular arrangement of the distal left renal vein. Obstruction of the proximal venous bed causes an increase in pressure in the renal vein, leading to the formation of renovarian reflux in the left ovarian veins with the development of chronic pelvic venous insufficiency.

May-Turner syndrome - compression of the left common vein iliac of the right common iliac artery - also acts as one of the etiologic factors for 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 and endovascular imaging methods into practice, this pathology is being discovered more and more often.

Classification

Varicose veins are divided into the following forms:

• The primary type of varicose veins: an increase in the blood vessels in the pelvis. The cause is valvular insufficiency of 2 types: acquired or congenital.
• The secondary form of thickening of the pelvic veins is diagnosed exclusively in the presence of pathologies with respect to gynecology (endometriosis, neoplasms, polycystic).

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

• First degree. Changes in the structure of the ovarian valve flaps may occur for hereditary reasons or be acquired. The disease is characterized by an increase in the diameter of the veins up to 5 mm. The left ovary has a pronounced enlargement in the outer parts.
• Second degree. This degree is characterized by the spread of pathology and damage to the left ovary. The veins in the uterus and right ovary can also be dilated. The expansion diameter reaches 10 mm.
• Third degree. The diameter of the veins increases up to 1 cm The dilation of the veins is observed equally on the right and left ovaries. This phase is due to pathological phenomena of a gynecological nature.

It is also possible to classify the disease according to the primary cause of its development. There is a primary degree where the enlargement is caused by defective function of the venous valves, and a secondary degree, which is a consequence of chronic gynecological diseases, inflammatory processes or complications of oncological nature. The degree of the disease may vary depending on the anatomical feature which indicates the location of the vascular disorder:

• Intra-throw abundance.
• Vulvar and perineal.
• Combined forms.

Symptoms and clinical manifestations

In women, pelvic varicose veins are accompanied by severe but non-specific symptoms. Often the manifestations of this disease are considered as signs of gynecological disorders. The main clinical symptoms of varicose veins in women with involvement of the pelvic vessels are:

• Non-menstrual pain in the abdomen. Their intensity depends on the stage of venous damage and the extent of the process. For 1st degree varicose veins in the small pelvis, periodic, mild pain extending to the lower back is characteristic. In later stages, it is felt in the abdomen, groin and lower back and is long and intense.
• Abundant mucus discharge. The so-called leukorrhoea does not have an unpleasant odor, does not change color, indicating an infection. The discharge volume increases in the second phase of the cycle.
• Increased symptoms of premenstrual syndrome and dysmenorrhea. Even before the onset of menstruation, pain increases in women, up to the occurrence of difficulty walking. During menstrual bleeding, it can become unbearable and spread to the entire pelvic region, groin, lower back and even to the thighs.
• Another characteristic sign of varicose veins in the groin in women is discomfort during intercourse. It is felt in the vulva and vagina and is characterized as a dull pain. It can be observed at the end of intercourse. In addition, the disease is accompanied by increased anxiety, irritability and mood swings.
• As with varicose veins in the small pelvis in men, in the female part of patients with such a diagnosis, the interest in sex gradually disappears. The cause of dysfunction is both constant discomfort and a decrease in the production of sex hormones. In some cases, infertility may occur.

Instrumental diagnostics

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

• The first stage is a routine examination by a gynecologist: take anamnesis, manual examination, ultrasound examination of the pelvic organs (to rule out other pathology). Based on the results, an examination is also prescribed by a proctologist, urologist, neurologist and other related specialists.
• If the diagnosis is not clear but VVPT is suspected, second-stage ultrasound angioscanning (USAS) of the pelvic veins is performed. This is a non-invasive, highly informative method of screening diagnostics used for all women with suspected VVPT. If previously it was thought that it was enough to examine only the pelvic organs (venous examination was considered difficult to access and optional), then ultrasound of the pelvic veins is currently a mandatory examination procedure. Using this method, it is possible to determine the presence of varicose veins in the small pelvis by measuring the diameters, the rate of blood flow in the veins and preliminary to find out what is the leading pathogenetic mechanism - failure of the ovarian veins or venous obstruction. This method is also used for dynamic assessment of conservative and surgical treatment of VVPT.
• Research is performed transvaginally and transabdominally. The veins in parametrium, groin-like plexuses and uterine veins are visualized transvaginally. According to various authors, the diameter of the vessels in the named locations varies 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 curved veins is 1, 1 ± 0, 4 mm. Veins larger than 5 mm in diameter are considered dilated. Inferior vena cava, iliac veins, left renal veins, and ovarian veins are examined transabdominally to rule out thrombotic masses and extravascular compression. The length of the left renal vein is 6 to 10 mm and its average width is 4 to 5 mm. Normally, the left renal vein at the site where it passes over the aorta is somewhat flattened, but a decrease in its transverse diameter by 2-2, 5 times occurs without a significant acceleration of blood flow, ensuring normal outflow without increasing the pressure in it. pretenotic. zone. In the case of stenosis of a vein due to pathological compression, there is a significant decrease in its diameter - by 3, 5-4 times and an acceleration of blood flow - over 100 cm / s. The sensitivity and specificity of this method are 78 and100%.
• Examination of the ovarian veins is included in the mandatory 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. A sign of ovarian failure in the USAS is considered to be more than 5 mm in diameter with the presence of retrograde blood flow. For a complete examination, prevention of relapse and proper treatment tactics, ultrasound of the veins of the lower extremities, perineum, vulva, inner thigh and gluteal region must be performed.
• The development of medical technology has led to the use of new diagnostic methods. In the third stage, after ultrasound verification of the diagnosis, radiation diagnostic methods 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. This method has long been considered the diagnostic "gold standard" for evaluating dilatation and detecting valvular insufficiency in the 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 installed in one of the main veins (jugular, brachial or femoral) to the iliac, renal and ovarian veins. Thus, it is possible to identify the anatomical variants of the structure of the ovarian veins, 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 a sharp expansion and tortuosity, respectively. This is the most accurate method for detecting May-Turner syndrome, post-thrombophlebitis changes in the hip and inferior vena cava.
• When the left renal vein is compressed, perirenal venous collaterals with retrograde blood flow into the gonadal veins, contrast stagnation in the renal vein is determined. The method measures the pressure gradient between the left kidney and the inferior vena cava. Normally it is 1 mm Hg. Nature. ; gradient equal to 2 mm Hg. Nature. , may suggest light compression; with a gradient >3 mm Hg. Art. can be diagnosed with aorto-mesenteric compression syndrome with hypertension in the left renal vein, and the gradient >5 mm Hg. Art. considered a hemodynamically significant stenosis of the left renal vein. Determining the pressure gradient is an important element in the diagnosis, as depending on its values, significantly different surgical procedures are planned on the veins in 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 ovarian vein embolization.
• The next radiation method is emission computed tomography of the pelvic veins with in vitro-labeled erythrocytes. It is characterized by the deposition of labeled erythrocytes in the veins of the pelvis and visualization of gonadal veins, makes it possible to identify varicose plexus in the small pelvis and dilated ovarian veins in different positions, the degree of pelvic venous congestion, reflux of blood from the pelvic veins into the saphenous veinsveins in the legs and groin. Usually the ovarian veins are not contrasted, the accumulation of radiopharmaceutical in venous plexus is not observed. For an objective assessment of the degree of venous congestion of the small pelvis, the coefficient of pelvic venous congestion is calculated. However, this method also has disadvantages: invasiveness, relatively low spatial resolution, the inability to accurately determine the diameter of the veins, therefore, it is currently not used as often in clinics.
• Video laparoscopic examination is a valuable tool for evaluating the undiagnosed. In combination with other methods, it can help determine the causes of pain and prescribe the correct treatment. With varicose veins in the small pelvis in the ovarian region, along the round and wide ligaments of the uterus, veins can be visualized in the form of cyanotic, dilated vessels with a diluted and tense wall. The use 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 case of suspected multifocal pain. Laparoscopy makes it possible to visualize the causes of CPP, for example foci of endometriosis or adhesions, in 66% of cases.

Functions of therapy

For full treatment of varicose veins in the small pelvis, a woman must follow all the doctor's recommendations and also change her lifestyle. First of all, pay attention to the loads, if they are too high, they should be reduced, if the patient leads an excessively sedentary lifestyle, it is necessary to practice sports, go for walks more often, etc.

Patients with varicose veins are strongly advised to adjust their diet, consume as little junk food as possible (fried, smoked, sweet in large quantities, salt, etc. ), alcohol, caffeine. It is better to prefer vegetables and fruits, dairy products, grains.

As a prophylaxis for the progression of the disease and for medical purposes, doctors also prescribe the use of compression underwear for patients with varicose veins.

Drugs

Therapy of ERCT involves several important points:

• to get rid of the reverse flow of venous blood;
• relief of symptoms of the disease;
• stabilization of vascular tone;
• improved blood circulation in tissues.

Preparations for varicose veins should be taken on courses. The rest of the drugs that play the role of painkillers must be taken exclusively during a painful attack. For effective therapy, the doctor often prescribes the following medications:

• phleboprotectors;
• enzyme preparations;
• drugs that relieve inflammatory processes with varicose veins;
• pills 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 fundamentally solved and the disease can only be completely eliminated by surgery. In modern medicine, there are many variations of surgical treatment of varicose veins, consider the most common and effective types of surgeries:

• embolization of veins in the ovaries;
• sclerotherapy;
• plastic of the uterine ligaments;
• removal of enlarged veins through laparoscopy;
• clamping of veins in the small pelvis with special medical clips (clipping);
• crossectomy - venous ligation (prescribed if, in addition to the pelvic organs, the vessels of the lower extremities are affected).

During pregnancy, only symptomatic treatment of varicose veins in the small pelvis is possible. We recommend wearing compression tights and taking phlebotonics on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of varicose veins in the perineum can be performed. If, due to varicose veins, there is a high risk of bleeding during spontaneous birth, the choice is made in favor of operative birth.

Physiotherapy

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

• "Bike". We lie on our backs, throw our hands behind our heads or place them along our bodies. We raise our legs and perform circular motions with them, as if we were pedaling a bicycle.
• "Birk". We sit face up on any hard, comfortable surface. Lift your legs up and start them gently behind your head. Support your lower back with your hands and place your elbows on the floor, slowly lowering your legs, lifting your body up.
• "Scissors". The starting position is on the back. Raise the closed legs slightly above floor level. We spread the lower limbs to the sides, return them back and repeat.

Possible complications

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

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

Prophylaxis

In order for varicose veins in the small pelvis to disappear as quickly as possible, and in the future there is no recurrence of the pathology of the pelvic organs, it is worth adhering to simple preventive rules:

• perform gymnastic exercises daily;
• prevent constipation;
• observe a diet where plant fibers must be present;
• do not stay in one position for a long time;
• take a contrast shower of perineum;
• so that varicose veins do not appear, it is better to wear unusually 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.