History

Fact Explanation
Pelvic discomfort Vulval varicosity is a distressing disorder occurring in 10% of pregnant women, generally during the latter half of a second pregnancy and usually regresses postpartum. It may produce pelvic discomfort.[1]. Women become extremely uncomfortable because of the bulk, tension, and warmth of one or both labia majora, especially in the posterior part. And also the mass is an embarrassment and a discomfort during sitting-and walking.[2].
Vulvar pressure and heaviness Maybe seen in vulval varices. heaviness and swelling increase on standing and reduce in the lying down position.[1].
Pruritus Some may experience pruritus in vulval area.[1].
Sensation of prolapse Vulval varices may produce pelvic discomfort, vulvar pressure, pruritus, a sensation of prolapse, and may extend into the vagina.[1].
Extend into the vagina Hormonal influences, prostaglandins A1, A2, E1, and E2, and scarcity of valves in the pelvic veins facilitating free and profuse crossover circulation lead to increased chances of vulvar varicosities in pregnancy, usually apparent after 26 weeks of gestation.The anastomotic nature of the venous network can result in downward extensions to the vagina and the medial aspect of the thigh, anteriorly to the groin and mons veneris, and posteriorly to the anal margin.[1].
Thrombosis Complications such as thrombosis or bleeding can occur. But fortunately they are rare.[1].
Bleeding Spontaneous bleeding appears to be of academic interest, and in practice is not observed. Bleeding during childbirth is associated with vaginal tears or an episiotomy. Internal bleeding results in the formation of a hematoma, primarily.affecting the labia. And vulvar varices are not an indication for a cesarean section delivery.[1].
Pain Vulvar varicose veins are rare in non-pregnant women. When present, they can be seen alone, associated with leg varices, or associated with venous malformations of the labia, clitoral area or vagina. In this case the patient presented with vulval and upper thigh varices associated with pelvic heaviness and pain radiating down the leg.The association of varices plus chronic pelvic pain can be secondary to PCS (Pelvic congestion syndrome). [3].
Dyspareunia It is estimated that over 30% of women will have chronic pelvic pain during life This chronic pelvic pain is often a manifestation of venous insufficiency of the gonadal and pelvic veins. In women, this is manifested by swelling in/of the vulva or vagina, as well as vulvar, buttock, and leg varicosities. Dyspareunia and abnormal menstrual bleeding might also result.[4].
References
  1. JINDAL S, DEDHIA A, TAMBE S, JERAJANI H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic Indian J Dermatol [online] 2014, 59(2):210 [viewed 18 August 2014] Available from: doi:10.4103/0019-5154.127757
  2. DODD H, WRIGHT HP. Vulval Varicose Veins in Pregnancy Br Med J [online] 1959 Mar 28, 1(5125):831-832 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824
  3. ASLAM M. I., FLEXER S. M., FIGUEIREDO R., ASHOUR H. Y., BHATTACHARYA V.. Successful embolization of vulval varices arising from the external pudendal vein. Journal of Surgical Case Reports [online] December, 2014(2):rjt129-rjt129 [viewed 19 August 2014] Available from: doi:10.1093/jscr/rjt129
  4. BEST IM. Management of an Unusual Iliac Fossa Venous Plexus Case Rep Vasc Med [online] 2011:140389 [viewed 19 August 2014] Available from: doi:10.1155/2011/140389

Examination

Fact Explanation
Dilated tortuous veins Partially compressible tortuous blue-colored swelling having a 'bag of worms feel' on palpation can be seen in labia majora, minora, and vagina .[1].
Vulval swelling Vulval veins may be distended from one or more of three sources of hypertension. They are the long saphenous vein through its incompetent tributaries, the superficial and deep external pubic veins and the spermatic veins passing with the round ligament from the labia majora into the inguinal canal and thence to the posterior abdominal wall to join the inferior venacava on the right and the renal vein on the left. Their varicosity causes a bulge in the groin like an inguinal hernia, with an increasing pear-shaped swelling of the labium major on the affected side, attaining grotesque proportions in the perineum. And it causes disfigurement. third one is the pudendal tributaries of the internal iliac vein also fill varices of the perineum,posterior part of the labia, and upper part of the postero-medial aspects of the thigh.[2].
Cough impulse Varicosity of the long saphenous and round ligament veins together has been found. The varicose round ligament veins would correspond to a varicocele of the spermatic veins in the male. They are denoted by a bulge in the inguinal canal, which steadily enlarges to the labium major and perineum. There is an impulse in these veins on coughing. Compression empties them, and they are largely controlled after emptying by pressure with the finger over the internal ring when the swelling remains smaller and softer, but reappears immediately the pressure is released. This control is not absolute, for there are usually contributory vessels frqm the long saphenous or pudendal veins.[3].
References
  1. JINDAL S, DEDHIA A, TAMBE S, JERAJANI H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic Indian J Dermatol [online] 2014, 59(2):210 [viewed 18 August 2014] Available from: doi:10.4103/0019-5154.127757
  2. DODD H, WRIGHT HP. Vulval Varicose Veins in Pregnancy Br Med J [online] 1959 Mar 28, 1(5125):831-832 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824
  3. DODD H, WRIGHT HP. Vulval Varicose Veins in Pregnancy Br Med J [online] 1959 Mar 28, 1(5125):831-832 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824

Differential Diagnoses

Fact Explanation
Inguinal hernia A hernia is an abnormal opening or defect through which organs or tissue may protrude.Inguinal hernias are much more difficult to diagnose in women than in men. It is typical for women to have nonpalpable or occult inguinal hernias. These can only be adequately evaluated laparoscopically.Diagnosis is suspected by pain distribution and tenderness over the internal ring. Symptoms include pain in the lower abdomen or groin when lifting, coughing, and sneezing with radiation into the labia majora and anterior thigh.[1],[2]. Indirect inguinal hernia is the most common hernia in women. It is congenital and due to nonclosure of the processus vaginalis. Tissue protrudes through the internal ring and passes down the inguinal canal a variable distance with the round ligament. Direct inguinal hernia is acquired and is the second most common inguinal hernia in women.[2].
Bartholin's gland cysts A differential diagnosis for vulval varices.[1].Bartholin's glands are outgrowths of the urogenital sinus and are analogous to Cowper's glands in the male. Their main function is to provide lubrication for sexual intercourse. A Bartholin's gland cyst is a cystic enlargement of the gland that develops from a blockage of one of the Bartholin's ducts as a result of a genital infection, inflammation or thickened mucus. A painless lump in the vulva area is the most common presenting sign. When a Bartholin's gland cyst becomes infected, it forms an abscess that is typically quite painful. An infected cyst should be drained and treated with antibiotics. Bartholin's gland cysts and abscesses are commonly found in women of reproductive age and develop in approximately 2% of all women. They are exceedingly rare before puberty.[3].
Pelvic Congestion Syndrome (PCS) Pain is the definitive symptom of PCS. It is usually described as a dull ache with intermittent acute exacerbations. Usually 1 side will predominate, but on careful questioning, the patient reveals that symptoms are felt occasionally on the non predominate side. The acute increases in pain will often have a sharp quality. Low backache is often present. All symptoms are aggravated by anything that increases venous pressure. Standing, walking, prolonged sitting, sexual intercourse, and vigorous sports activities will usually exacerbate the symptoms.Both deep thrust dyspareunia (71% to78%) and postcoital aching (65%) are common complaints.Menstrual disorders, such as menorrhagia and menometrorrhagia, occur in up to 54% of patients. Intermenstrual bleeding may be present in up to 25%. Gastrointestinal and urinary tract symptoms are common. Bloating, nausea, and diffuse abdominal cramping are common.An abdominal examination will produce tenderness over the ovarian points.On inspection of the external genitalia, superficial varicosities may be noted.Visualization of the cervix may reveal cyanosis and an increase of cervical mucous. The uterus and ovaries are tender. The uterus may be retroverted.[4].
References
  1. JINDAL S, DEDHIA A, TAMBE S, JERAJANI H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic Indian J Dermatol [online] 2014, 59(2):210 [viewed 18 August 2014] Available from: doi:10.4103/0019-5154.127757
  2. PERRY CP, ECHEVERRI JD. Hernias as a Cause of Chronic Pelvic Pain in Women JSLS [online] 2006, 10(2):212-215 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016116
  3. EL KADY S, AL ZAHRANI A, JEDNAK R, EL SHERBINY M. Bartholin's gland abscess in a neonate: a case report Can Urol Assoc J [online] 2007 Jun, 1(2):117-119 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2422937
  4. PERRY CP. Current Concepts of Pelvic Congestion and Chronic Pelvic Pain JSLS [online] 2001, 5(2):105-110 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015423

Investigations - for Diagnosis

Fact Explanation
Doppler sonography Doppler sonography with deep inspiration and expiration is the preferred method of investigation. During pregnancy, Doppler sonography is especially requested in some situations.they are early-onset vulvar varices (first two months of a first pregnancy), to look for a malformation,Unilateral vulvar varices (malformation, left iliac thrombosis) and Superficial thrombosis of a vulvar varicose vein, to look for deep vein thrombosis.[1].
Laparoscopy It is an invasive investigation. It is used especially preoperatively to accurately delineate the varices.[1].
Venography Varicose veins in the vulvar and peri-vulvar area are seen in 4% of women and most commonly seen during pregnancy. It is thought to be as a direct result of the presence of ovarian and pelvic varicosities. Diagnostic modalities used in the investigation of this condition included computed venography, magnetic resonance venography and catheter-directed venography.Catheter venography is invasive and is used to confirm the diagnosis immediately before embolization. There are characteristic findings on radiological imaging. Assessed on venography. Specific findings include an ovarian vein diameter of >10 mm along with congestion of the ovarian plexus. The reflux of blood and dilatation of the veins is due to an absence of functioning valves, particularly in the ovarian veins. However, there are other veins that can be responsible for vulval varicosities.Rarely from superficial external pudendal vein.[2].
Pelvic Ultrasound Pelvic ultrasound is another diagnostic modality used in the investigation of this condition.Both transabdominal and transvaginal Ultrasound are used.[2].
References
  1. JINDAL S, DEDHIA A, TAMBE S, JERAJANI H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic Indian J Dermatol [online] 2014, 59(2):210 [viewed 18 August 2014] Available from: doi:10.4103/0019-5154.127757
  2. ASLAM M. I., FLEXER S. M., FIGUEIREDO R., ASHOUR H. Y., BHATTACHARYA V.. Successful embolization of vulval varices arising from the external pudendal vein. Journal of Surgical Case Reports [online] December, 2014(2):rjt129-rjt129 [viewed 19 August 2014] Available from: doi:10.1093/jscr/rjt129

Management - General Measures

Fact Explanation
Conservative measures As the varicosities tend to regress postpartum, the management is essentially conservative in the form of leg elevation, left-sided sleeping, compression hose, exercise, and the avoidance of sustained periods of sitting or standing.[1].
Vulval compression/ Support Vulval varicosities have been so gross before the 30th week of gestation. The postnatal surgery in such cases would be easier than during pregnancy, is mistaken, since such vulval veins in the collapsed state are extremely difficult to identify and eradicate. So that vulval support is the best practical treatment, and the usual practice is to advise the women to wear a fairly tight disposable sanitary pad, which has the advantage of being hygienic, easily obtained, and cheap.[4].
Sclerotherapy Active treatment, in the form of sclerotherapy (with 1% sodium tetradecyl sulfate, polidocanol, aetoxisclerol, and polyiodinated iodine) is deemed appropriate in postpartum patients in cases of Unsightly or very symptomatic varicosities, to the extent of immobilizing the patient with pain, particularly during the third trimester ,Superficial thrombophlebitis or Symptoms persisting beyond six weeks of the postpartum period (this appears to be a sufficient length of time to allow for spontaneous resolution).[1].
Sapheno femoral ligation Where clear signs of venous incompetence were found, which was causing considerable distress not relieved by other measures, operation has been advised, up to the end of the seventh month. Varicosity of the labium major requires exploration of the sapheno-femoral junction and its ligation if incompetent, together with the tributaries joining, followed by excision of the round ligament with the associated distended veins. This is done under a bland general anaesthetic.[2].
Hysterectomy and/or ligation of ovarian veins The treatment options in the past were hysterectomy and/or ligation of ovarian veins by open or laparoscopic approach.[3].
Laparoscopic ligation of the ovarian veins. The traditional treatment has been replaced with laparoscopic ligation of the ovarian veins. However, this approach can result in transaction of the nerves to the pelvis and still leave the possibility of establishing collateral channels resulting in symptomatic recurrence.[3].
Local excision Local excision can also be attempted. Left untreated, vulvar varicosities can persist and sometimes get worse in subsequent pregnancies.[1].
References
  1. JINDAL S, DEDHIA A, TAMBE S, JERAJANI H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic Indian J Dermatol [online] 2014, 59(2):210 [viewed 18 August 2014] Available from: doi:10.4103/0019-5154.127757
  2. DODD H, WRIGHT HP. Vulval Varicose Veins in Pregnancy Br Med J [online] 1959 Mar 28, 1(5125):831-832 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824
  3. ASLAM M. I., FLEXER S. M., FIGUEIREDO R., ASHOUR H. Y., BHATTACHARYA V.. Successful embolization of vulval varices arising from the external pudendal vein. Journal of Surgical Case Reports [online] December, 2014(2):rjt129-rjt129 [viewed 19 August 2014] Available from: doi:10.1093/jscr/rjt129
  4. DODD H, WRIGHT HP. Vulval Varicosities in Pregnancy Br Med J [online] 1959 May 30, 1(5134):1412 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993582

Management - Specific Treatments

Fact Explanation
Embolization of the varicosity The most commonly performed technique now is embolization of the responsible veins using interventional radiology. The technique was described by Edwards in 1993 and has gained popularity by both clinicians and patients. Transcatheter embolotherapy is now the preferred treatment for PCS. This is performed with a combination of sclerosant foam and/or coils to embolize the source veins. Clinical success is achieved in 70–85% of treated patients.[1].
References
  1. ASLAM M. I., FLEXER S. M., FIGUEIREDO R., ASHOUR H. Y., BHATTACHARYA V.. Successful embolization of vulval varices arising from the external pudendal vein. Journal of Surgical Case Reports [online] December, 2014(2):rjt129-rjt129 [viewed 19 August 2014] Available from: doi:10.1093/jscr/rjt129