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What will the dilated veins of the small pelvis say in women?

From the article, you will learn the characteristics of varicose veins of the small pelvis in women - this is a deformation of the veins of the pelvic region with poor blood flow to the internal and external genital organs.

varicose veins of the small pelvis

General information

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

In the vast majority of cases (80%), varicose transformation affects the ovarian veins and is extremely rare (1%) seen in the veins of the broad ligament of the uterus. According to modern medical approaches, the treatment of VVMT should be carried out not so much from the point of view of gynecology, but, first of all, from the point of view of phlebology.

Pathology triggers

Under the varicose veins of the pelvic organs in women, doctors understand a change in the structure of the vascular walls characteristic of other types of disease: weakening followed by stretching and formation of "pockets" within which the blood stagnates. . Cases in which only the vessels of the pelvic organs are affected are extremely rare. In about 80% of patients, along with this form, there are signs of varicose veins of the inguinal veins, vessels of the lower extremities.

The incidence of varicose veins of the small pelvis is more 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 cyclical menstrual periods, during pregnancy and during sexual intercourse.

All these phenomena belong to the category of factors that cause varicose veins. And they are found exclusively in women. The greatest number of patients are faced with varicose veins of the small pelvis during pregnancy, since there is a simultaneous overlap of provoking factors. According to statistics, among men, varicose veins of the small pelvis are 7 times less common than among the more blond sex. They have a more diverse set of provoking factors:

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

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

The increased risk of developing inguinal varicose veins in women with pelvic vessel involvement is observed in patients with venous pathology in other parts of the body. In this case, we are talking about congenital weakness of the veins.

Ethiopathogenesis

Proctologists believe that the following main reasons always contribute to the development of PVV: valve regurgitation, venous obstruction, and hormonal changes.

Pelvic venous congestion syndrome 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 genetic in nature. FOXC2 was one of the first genes identified that plays a key role in the development of VVP. Currently, the relationship between the development of the disease and genetic mutations (TIE2, NOTCH3), the level of thrombomodulin and the transforming growth factor β type 2 has been determined. These factors contribute to a change in the structure of the valve itself. or of the venous wall; all this leads to the failure of the valve structure; enlargement of the vein, which causes a change in the function of the valve; progressive reflux and finally varicose veins.

Connective tissue dysplasia can play an important role in the development of the disease, the morphological basis of which is a decrease in the content of various types of collagen or a violation of the ratio between them, which leads to a decrease in the strength of the veins. .

The incidence of PVV is directly proportional to the amount of hormonal changes, which are especially pronounced during pregnancy. In pregnant women, the capacity of the pelvic veins increases by 60% due to the mechanical compression of the pelvic vessels by the pregnant uterus and the vasodilator effect of progesterone. This venous dilation persists for a month after delivery and can cause venous valve insufficiency. Also, during pregnancy, the mass of the uterus increases, its position changes occur, which causes 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, including hard physical labor, and prolonged forced position (sitting or standing) during the workday.

The formation of varicose veins in the small pelvis is also facilitated by the anatomical features of the outflow of the small pelvic veins. The diameter of the ovarian veins is usually 3-4 mm. The long, thin ovarian vein on the left flows into the left renal vein and, on the right, into the inferior vena cava. Normally, 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 avoids compression of the left renal vein. On average, the angle between the aorta and the superior mesenteric artery in adults is 51 ± 25 °, in children - 45. 8 ± 18. 2 ° in boys, and 45. 3 ± 21. 6 ° in girls. In the case of a decrease in 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 is of the greatest clinical importance. Posterior nutcracker syndrome occurs rarely in patients with a retro-aortic or annular arrangement of the distal left renal vein. Obstruction of the proximal venous bed causes increased pressure in the renal vein, which leads to the formation of renoovarian reflux in the left ovarian vein with the development of chronic pelvic venous insufficiency.

May-Turner syndrome (compression of the left common iliac vein by the right common iliac artery) also serves as one of the etiologic factors of varicose veins in the pelvis. Occurs in no more than 3% of cases, it is found more frequently in women. Currently, due to the introduction into practice of radiation and endovascular imaging methods, this pathology is increasingly detected.

Classification

Varicose veins are subdivided into the following forms:

  • The main type of varicose veins - an increase in the blood vessels of the pelvis. The reason is valve insufficiency of 2 types: acquired or congenital.
  • The secondary form of thickening of the pelvic veins is diagnosed exclusively in the presence of pathologies in terms of gynecology (endometriosis, neoplasms, polycystosis).

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

It is also possible to classify the disease based on the main cause of its development. There is a primary degree, in which the expansion is caused by a malfunction of the venous valves, and a secondary degree, which is a consequence of chronic female diseases, inflammatory processes or complications of an oncological nature. The degree of the disease may differ depending on the anatomical feature, which indicates the location of the vascular disorder:

  • Intracaste plethora.
  • Vulvar and perineal.
  • Combined forms.

Symptoms and clinical manifestations.

In women, pelvic varicose veins are accompanied by severe but nonspecific symptoms. Often the manifestations of this disease are considered signs of gynecological disorders. The main clinical symptoms of varicose veins in the groin in women with pelvic vessel involvement are:

pain in the lower abdomen with varicose veins of the small pelvis
  • Non-menstrual pain in the lower abdomen. Its intensity depends on the stage of venous damage and the extent of the process. For the first degree of varicose veins of the small pelvis, periodic and mild pain, extending to the lower back, is characteristic. In later stages, it is felt in the abdomen, perineum, and lower back, and is long and intense.
  • Profuse mucous dischargeThe so-called leucorrhoea does not have an unpleasant odor, it does not change color, which would indicate an infection. The discharge volume increases in the second phase of the cycle.
  • Increased symptoms of PMS and dysmenorrhea. Even before the onset of menstruation, pain in women increases, until the appearance of walking difficulties. During menstrual bleeding, it can become unbearable and spread to the entire pelvic region, the perineum, the lower back, and even the thighs.
  • Another characteristic sign of varicose veins in the groin in women is discomfort during sexual intercourse. It is felt on the vulva and vagina and is characterized as a dull ache. It can be observed at the end of intercourse. Also, the disease is accompanied by increased anxiety, irritability, and mood swings.
  • As with varicose veins of the small pelvis in men, in the female part of patients with such a diagnosis, 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 can occur.

Instrumental diagnosis

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

  • The first stage is a routine examination by a gynecologist: anamnesis, manual examination, ultrasound examination of the pelvic organs (to exclude another pathology). Based on the results, an examination is also prescribed by a proctologist, urologist, neurologist and other related specialists.
  • If the diagnosis is unclear, but there is a suspicion of TPV, in the second stage, an ultrasound angiography (USAS) of the pelvic veins is performed. This is a non-invasive and highly informative method of screening diagnosis, which is used in all women with suspected TPV. If earlier it was believed that it was enough to examine only the pelvic organs (examination of the veins was considered difficult to access and optional), then at the current stage ultrasound of the pelvic veins is a mandatory examination procedure. With the help of this method, it is possible to establish the presence of varicose veins of the small pelvis by measuring the diameters, the speed of blood flow in the veins and, preliminarily, find out what is the main pathogenetic mechanism - the failure of the veins. ovarian or venous obstruction. In addition, this method is used for the dynamic evaluation of conservative and surgical treatment of TPVL.
  • Research is carried out transvaginally and transabdominally. The parametrial veins, groin-shaped plexuses, and uterine veins are visualized transvaginally. According to different 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), that is to say. no more than 5 mm, and the mean diameter of the arcuate veins is 1. 1 ± 0. 4 mm. Veins larger than 5mm in diameter are considered dilated. The inferior vena cava, iliac veins, left renal vein, and ovarian veins are examined transabdominally to exclude thrombotic masses and extravasal 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 place where it passes over the aorta is somewhat flattened, but there is a decrease in its transverse diameter by 2 to 2. 5 times without a significant acceleration of blood flow, which ensures an outflow normal without increasing the pressure in the pretenotic. zone. In the case of stenosis of a vein in the context of pathological compression, there is a significant decrease in its diameter, from 3, 5 to 4 times, and an acceleration of blood flow, above 100 cm / s. The sensitivity and specificity of this method is 78 and 100%, respectively.
  • The examination of the ovarian veins is included in the mandatory examination of the pelvic veins. They are found along the anterior abdominal wall, along the rectus abdominis muscle, slightly lateral to the iliac veins and arteries. A sign of ovarian vein insufficiency in USAS is considered to be more than 5 mm in diameter with the presence of retrograde blood flow. For a complete examination, relapse prevention, and correct treatment tactics, an ultrasound of the veins of the lower extremities, perineum, vulva, inner thigh, and buttock region should 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 venography with selective bilateral radiopaque ovariocography is one of the invasive radiation diagnostic methods performed only in a hospital setting. This method has long been considered the diagnostic "gold standard" for evaluating dilatation and detecting valve regurgitation in the pelvic veins. The essence of the method is the introduction of a contrast medium under the control of an X-ray facility 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 the gonadal and pelvic veins.
  • The retrograde contrast of the gonadal veins at the height of the Valsalva test serves as a pathognomonic angiographic sign of her valve regurgitation with visualization of an acute expansion and tortuosity, respectively. This is the most accurate method to detect May-Turner syndrome, post-thrombophlebitic changes in the iliac and inferior vena cava.
  • When the left renal vein is compressed, the perirenal venous collaterals with retrograde blood flow to the gonadal veins are determined, contrast stagnation in the renal vein. The method measures the pressure gradient between the left kidney and the inferior vena cava. Typically, it is 1 mm Hg. Art . ; gradient equal to 2 mm Hg. Art. , May suggest slight compression; with a gradient >3 mm Hg. Art. Aorto-mesenteric compression syndrome can be diagnosed with hypertension in the left renal vein and gradient>5 mm Hg. Art. it is considered a hemodynamically significant stenosis of the left renal vein. The determination of the pressure gradient is an important element of the diagnosis, since, depending on its values, essentially different surgical interventions are planned in the veins of 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 embolization of the ovarian veins.
  • The next radiation method is pelvic vein emission computed tomography with in vitro labeled erythrocytes. It is characterized by the deposition of marked erythrocytes in the veins of the pelvis and the visualization of the gonadal veins, it allows to identify the varicose plexuses of the small pelvis and the ovarian veins dilated in various positions, the degree of pelvic venous congestion, the reflux of blood from the pelvic veins into the saphenous veins of the legs and perineum. Normally, the ovarian veins are not contrasted, there is no accumulation of the radiopharmaceutical in the venous plexuses. For an objective assessment of the degree of venous congestion of the small pelvis, the coefficient of pelvic venous congestion is calculated. But this method also has disadvantages: invasiveness, relatively low spatial resolution, the inability to accurately determine the diameter of the veins, therefore it is not used so often in clinics today.
  • 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 of the small pelvis in the ovarian region, along the round and broad ligaments of the uterus, the veins can be visualized as cyanotic dilated vessels with a taut, thinned wall. The use of this method is significantly limited by the following factors: the presence of retroperitoneal fatty tissue, the possibility of evaluating varicose veins only in a limited area, and the inability to determine reflux through the veins. Currently, the use of this method is justified diagnostically in cases 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.

Therapy characteristics

For the complete treatment of varicose veins of the small pelvis, a woman should follow all the recommendations of the doctor, and also change her lifestyle. First of all, she should pay attention to the loads, if they are excessively high, they should be reduced, if the patient leads an excessively sedentary lifestyle, it is necessary to play sports, walk 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, salty, etc. ), alcohol, caffeine. It is better to give preference to vegetables and fruits, dairy products, cereals.

Also, as a prophylaxis for the progression of the disease and for medicinal purposes, doctors prescribe the use of compression underwear for patients with varicose veins.

Medicines

ESRD therapy involves several important points:

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

Preparations for varicose veins should be taken in courses. The rest of the drugs, which play the role of painkillers, can be drunk exclusively during a painful attack. For effective therapy, the doctor usually prescribes the following medications:

  • phleboprotectors;
  • enzyme preparations;
  • drugs that relieve inflammatory processes with varicose veins;
  • Pills to improve blood circulation.

Operative treatment

It is worth recognizing 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 be completely eliminated only by surgery. In modern medicine, there are many variations of surgical treatment of varicose veins, consider the most common and effective types of operations:

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

During pregnancy, only symptomatic therapy of varicose veins of the small pelvis is possible. We recommend wearing compression stockings, taking phlebotonics on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of the varicose veins of the perineum can be performed. If, due to varicose veins, there is a high risk of bleeding during spontaneous delivery, surgical delivery is chosen.

Physiotherapy

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

  • "Bike". We lie on our back, put our hands behind the head or place them along the body. Raising our legs, we make circular movements with them, as if we were pedaling a bicycle.
  • "Birch". We sit on our backs on any hard and comfortable surface. Lift your legs up and gently put them behind your head. Supporting the lumbar region with your hands and resting your elbows on the floor, slowly stretch your legs lifting your body.
  • "Pair of scissors". The starting position is on the back. Raise your closed legs slightly above ground level. We extend the lower extremities to the sides, return them back and repeat.

Possible complications

Why are small pelvic varicose veins 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 soon as possible and in the future there is no recurrence of the pathology of the pelvic organs, it is worth following simple preventive rules:

  • perform gymnastic exercises daily;
  • prevent constipation;
  • observe a dietary regimen, in which vegetable fiber must be present;
  • do not stay in one position for a long time;
  • take a contrast shower of the perineum;
  • so that varicose veins do not appear, it is better to wear exceptionally comfortable shoes and clothing.

Preventive measures aimed at reducing the risk of the appearance and progression of varicose veins in the small pelvis are mainly reduced to the normalization of lifestyle.