Introduction

Varicose veins, especially during pregnancy, are very common. Diagnosis and treatment of vascular pathology leading to varicosities has advanced significantly in the past decade.

Epidemiology

It is estimated that 4 percent of women have vulvar varicosities. Twenty percent of pregnant women develop vulvar varicosities (varicose veins) during the pregnancy with spontaneous regression during the pospartum period.

Etiology

Vulvar varicosities result from venous obstruction, increased venous pressure, and venous insufficiency. They occur most commonly during pregnancy. Vulvar varicosities in pregnancy are related to changing hormonal levels, particularly of progesterone, which causes relaxation of any smooth muscle, including that inside of the walls of the veins. The growing size of the pregnant uterus can also cause compression to blood vessels.

Varicosities may be isolated or associated with varices of the lower extremity. Up to one-half of vulvar varicosities arise from an incompetent great saphenous vein, which drains the superficial and deep external pudendal veins and posteromedial tributaries.

Insufficiency of the internal iliac and ovarian veins may also contribute to development of varicose veins over the territories of their main tributaries (ie, the internal pudendal and obturator veins). Such varices can be large, have frequent anastomoses, and involve the vulva and posteromedial aspect of the thigh.

Vulvar varicosities may occur as part of the pelvic congestion syndrome (PCS), although the etiology and diagnostic criteria for this condition are not clear. Marked venous dilatation, incompetence, and reflux of the ovarian veins are reported leading to attribution of PCS to underlying venous pathology. A recent report of 57 women with severe symptoms found combined gonadal annd internal iliac venous insufficiency.

Symptoms and clinical features

Varicosities may be aymptomatic. or may escape detection because they may not be readily apparent on examination in the dorsal lithotomy position. Patients should be examined in the standing position.

Symptoms include feelings of pressure, swelling, aching discomfort, and itchiness. Symptoms are often exacerbated by prolonged standing, exercise, and sexual intercourse. Rupture causes bruising and even extensive bleeding. Engorged veins that are bluish in color or swollen, reddened vulvar tissue are typical. (PICTURE, 20-4, Lynne). They may appear as blue-purple distensible folds in the vaginal mucosa or as grape like clusters (“bag of worms”) on the vulva. Other varicosities may be seen on the buttocks, thighs, or lower extremities.

Diagnosis

Diagnosis is usually based on the clinical appearance. Compression of the vein makes it disappear (use a glass slide).

Varicosities may escape detection because they may not be readily apparent on examination in the dorsal lithotomy position. Patients should be examined in the standing position.

Consensus on use of imaging has not been reached, but with extensive varicosities a vascular consult through a teaching hospital may be indicated. Imaging may be helpful in planning therapy, especially since varicosities related to incompetence of ovarian veins and/or internal iliac veins may recur after local therapy. Duplex ultrasound studies of the lower extremity veins (even in the absence of lower leg varicosities) may reveal connections to the saphenous system and incompetent saphenous valves.

Magnetic resonance (MR) imaging or computed tomography (CT) are also used evaluate pelvic and gonadal veins in patients with vulvar varicosities. If imaging is positive, venography may demonstrate ovarian vein reflux that can be treated by embolization.

Vulvar varicosities associated with chronic pelvic pain should be evaluated with pelvic imaging as part of the work-up.

Pathology/Laboratory Findings

Biopsy is not necessary since the clinical features are characteristic.

Differential diagnosis

Arteriovenous or venous malformations, hernia, hematoma (if there is a history of recent trauma, hemangioma, Bartholin cyst.

Treatment

Noninvasive therapy is utilized during pregnancy because regression commonly occurs postpartum. Supportive therapies include vulvar support and compression (pelvic supporter), leg elevation, compression with support hose, sleeping on the left side, exercise, and avoidance of long periods of standing or sitting.

Vascular surgeons treat vulvar varices with sclerotherapy, ligation and excision, or embolization depending on the individual case. Isolated varices can be injected by sclerotherapy; if there is saphenous vein insufficiency the veins in the lower extremity are treated first, with treatment response of the vulvar varices to follow.

Laser or radiofrequency ablation, available for the treatment of the lower extremity is rarely possible for vulvar varicosities that generally do not meet criteria for these treatment modalities because of the size and location of the veins.

PCS with vulvar varices is treated with sugery or embolization for ovarian vein reflux.