What will the dilated veins of the small pelvis tell women?

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

varicose veins of small pelvic vessels

General Information

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

In most cases (80%), varicose transformation affects the ovarian vessels and is very rare (1%) in the vessels of the large uterine ligament. According to modern medical approaches, the treatment of VVMT should be carried out not from the point of view of gynecology, but primarily from the point of view of phlebology.

Pathology triggers

In women, under the varicose veins of the pelvic organs, doctors see a change in the structure of the vascular walls, which is characteristic of other types of disease - weakening, followed by the formation of "pockets" that stretch and stagnate. It is very rare that only the vessels of the pelvic organs are affected. In addition to this form, about 80% of patients have symptoms of varicose veins of the inguinal veins, veins of the lower extremities.

The frequency of varicose veins of the small pelvis is most pronounced in women. This is due to anatomical and physiological features and shows 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 characteristic of pregnancy;
  • cycles of more active filling of the veins with blood, including cyclic menstrual periods, during pregnancy, as well as during sexual intercourse.

All these events belong to the category of factors that provoke varicose veins. And they only happen in women. Most patients experience varicose veins of small pelvic vessels during pregnancy because there is a stratification of stimuli at the same time. According to statistics, varicose veins of the small pelvis among men are 7 times less than in the fairer sex. They have a more diverse set of motivating factors:

  • hypodynamics - prolonged maintenance 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 open refusal to have sex.

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

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

Etiopathogenesis

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

Pelvic venous occlusion syndrome can develop due to congenital absence or deficiency of venous valves, which was discovered by anatomical studies in the last century, and modern data confirm this.

It was also found that varicose veins in 50% of patients are genetic. FOXC2 was one of the first identified genes to play a key role in the development of VVP. At present, a link has been established between the development of the disease and gene mutations (TIE2, NOTCH3), thrombomodulin levels, and type 2 transforming growth factor β. These factors contribute to changes in the structure of the valve itself or the venous wall - all of which lead to valve structure failure; vasodilation, which causes changes in valve function; progressive reflux and consequent varicose veins.

An important role in the development of the disease may be connective tissue dysplasia, the morphological basis of which is a decrease in the content of different types of collagen or a violation of the ratio between them, which leads to a decrease in vascular strength. .

The frequency of VVP is directly proportional to the amount of hormonal changes that are particularly noticeable during pregnancy. In pregnant women, the capacity of the pelvic vessels increases by 60% as a result of mechanical compression of the pelvic vessels by the pregnant uterus and the vasodilating effect of progesterone. This venous dilatation lasts for one month after birth and can lead to venous valve insufficiency. In addition, during pregnancy, the weight of the uterus increases, its position changes, which leads to elongation of the ovarian vessels, which then leads to venous occlusion.

Risk factors also include endometriosis and other inflammatory diseases of the female reproductive system, estrogen therapy, unfavorable working conditions for pregnant women, including heavy physical labor and prolonged forced position (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 exit from the small pelvic vessels. The diameter of the ovarian vessels is usually 3-4 mm. The long and thin ovarian vein on the left flows into the left renal vein and 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 prevents compression of the left renal vein. The average 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. When the angle decreases 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 rarely occurs in patients with a retroaortic or annular structure of the distal left renal vein. Obstruction of the proximal venous bed leads to 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 etiological factors of varicose veins in the pelvis. It occurs in no more than 3% of cases and is more common in women. Currently, due to the use of radiation and endovascular imaging methods, this pathology is becoming more and more common.

Classification

Varicose veins are divided into the following forms:

  • The main type of varicose veins: enlargement of the pelvic vessels. The reason is 2 types of valve insufficiency: acquired or congenital.
  • The secondary form of pelvic vascular thickening is diagnosed only in the presence of gynecological pathologies (endometriosis, neoplasms, polycystic).

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

  • First degree. Changes in the structure of the valves of the ovaries can occur or be inherited. The disease is characterized by an increase in the diameter of the vessels up to 5 mm. There is an open enlargement on the outer parts of the left ovary.
  • Second degree. This degree is characterized by the spread of pathology and damage to the left ovary. The blood vessels in the uterus and right ovary can also dilate. The diameter of the expansion reaches 10 mm.
  • Third degree. The diameter of the vessels increases up to 1 cm. Dilation of blood vessels is observed equally in the right and left ovaries. This stage is associated with pathological events of a gynecological nature.

It is also possible to classify depending on the primary cause of the disease. There are primary and secondary gynecological diseases, inflammatory processes or oncological complications caused by the malfunction of the venous valves. The degree of the disease may vary depending on the anatomical features that indicate the location of the vascular disorder:

  • Abundance within the caste.
  • Vulvar and perineal.
  • Mixed forms.

Symptoms and clinical manifestations

In women, pelvic varicose veins are accompanied by severe but non-specific symptoms. Manifestations of this disease are often considered as symptoms of gynecological disorders. The main clinical symptoms of varicose veins in the groin in women with pelvic vascular obstruction are:

pain in the lower abdomen with varicose veins of the lower pelvis
  • Non-menstrual pain in the lower abdomen. Their intensity depends on the stage of venous damage and the degree of the process. Grade 1 varicose veins of the small pelvis are characterized by periodic, mild pain extending to the lower back. In the later stages, it is felt in the abdomen, perineum and lumbar region and becomes long and dense.
  • Abundant mucous discharge. It does not have an unpleasant odor called leucorrhoea and does not change color, which indicates the presence of infection. In the second stage of the period, the volume of discharge increases.
  • Increased symptoms of premenstrual syndrome and dysmenorrhea. Before the onset of menstruation, the pain in women increases until they have difficulty walking. It can become unbearable during menstrual bleeding, spreading to the entire pelvic region, perineum, lower back and even the thighs.
  • Another characteristic symptom of varicose veins in the groin in women is discomfort during sexual intercourse. It is felt in the vulva and vagina and is characterized as dull pain. It can be observed at the end of sexual intercourse. In addition, the disease is accompanied by increased anxiety, irritability and mood swings.
  • In men, as in small pelvic varicose veins, in women with such a diagnosis, interest in sex gradually disappears. The cause of dysfunction is both constant anxiety and decreased production of sex hormones. In some cases, infertility can occur.

Instrumental diagnostics

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

  • The first stage is a regular examination by a gynecologist: anamnesis, manual examination, ultrasound examination of the pelvic organs (to exclude other pathologies). Based on the results, an additional examination is scheduled by a proctologist, urologist, neurologist and other related specialists.
  • If the diagnosis is unclear, but VVPT is suspected, pelvic vascular ultrasound angioscanning (USAS) is performed in the second stage. It is a non-invasive, highly informative screening diagnostic method used in all women with suspected VVPT. If previously it was believed that only examination of the pelvic organs was sufficient (vascular examination was considered difficult and optional), now at this stage ultrasound examination of the pelvic vessels is a mandatory examination procedure. With the help of this method, it is initially possible to determine the presence of varicose veins in the small pelvis by measuring the speed and diameter of blood flow in the veins and to find out what is the leading pathogenetic mechanism. ovarian or venous obstruction. This method is also used to dynamically evaluate conservative and surgical treatment of VVPT.
  • The study is transvaginal and transabdominal. The vessels of the parametrium, the inguinal plexuses, and the uterine veins are visualized transvaginally. According to various authors, the diameter of the vessels of the above-mentioned localizations varies between 2, 0 and 5, 0 mm (average 3, 9 ± 0, 5 mm), ie. The average diameter of arched vessels not exceeding 5 mm is 1, 1 ± 0, 4 mm. Veins larger than 5 mm in diameter are considered dilated. To rule out thrombotic masses and extravasal compressions, the inferior vena cava, iliac veins, left renal vein, and ovarian veins are examined transabdominally. The length of the left renal vein is 6-10 mm, and the average width is 4-5 mm. Normally, the left renal vein where it passes through the aorta is slightly flattened, but a 2-2. 5-fold decrease in its transverse diameter occurs without significant acceleration of blood flow, which ensures normal outflow without increasing pretenotic pressure. zone. In the case of stenosis of a vessel on the background of pathological compression, a significant reduction in its diameter - 3, 5-4 times, and the acceleration of blood flow - more than 100 cm / s. The sensitivity and specificity of this method are 78 and 100%, respectively.
  • Examination of the ovarian vessels includes a mandatory examination of the pelvic veins. They are located along the anterior wall of the abdomen, along the smooth abdominis muscle, slightly to the side of the iliac veins and arteries. Symptoms of ovarian failure in USAS are considered to be more than 5 mm in diameter with retrograde blood flow. For a complete examination, relapse prevention and proper treatment tactics, ultrasound examination of the veins of the lower extremities, perineum, vulva, inner thigh and gluteal region should be performed.
  • The development of medical technology has led to the use of new diagnostic methods. In the third stage, radiation diagnostic methods are used to confirm the diagnosis after ultrasound examination.
  • Pelvic phlebography with selective bilateral radiopaque ovariography is one of the methods of radiation invasive diagnosis performed only in a hospital setting. This method has long been considered the diagnostic "gold standard" for assessing dilatation and detecting valve insufficiency in pelvic vessels. The essence of the method is the introduction of a contrast agent under the control of an X-ray device through a catheter inserted into the iliac, renal and ovarian vessels in one of the main vessels (neck, brachial or femoral). Thus, it is possible to determine the anatomical variants of the structure of the ovarian veins, to determine the diameters of the genitals and pelvic vessels.
  • The retrograde contrast of the gonadal vessels at the height of the Valsalva test serves as a pathognomonic angiographic sign of their valve insufficiency, with visualization of sharp dilation and flexion, respectively. This is the most accurate way to detect May-Turner syndrome, post-thrombophlebitis changes in the iliac and inferior vena cava.
  • When the left renal vein is constricted, perirenal venous collaterals with retrograde blood flow to the gonadal veins, contrast stagnation in the renal vein is detected. The method measures the pressure gradient between the left kidney and the inferior vena cava. It is normally 1 mm Hg. Art. ; the gradient is 2 mm Hg. Art. , may offer light compression; gradient>With 3 mm Hg. Art. Aorto-mesenteric compression syndrome with hypertension in the left renal vein can be diagnosed and gradient>5 mm Hg. Art. hemodynamically significant stenosis of the left renal vein. Determining the pressure gradient is an important element of the diagnosis, because depending on its values, fundamentally different surgical interventions are planned for small pelvic vessels, which is very important in modern conditions. Currently, this study (with a normal pressure gradient) can be used for therapeutic purposes - for embolization of ovarian vessels.
  • The next radiation method is computed tomography of the pelvic vessels with in vitro labeled erythrocytes. It is characterized by the deposition of labeled erythrocytes in the pelvic vessels and visualization of gonadal veins, allows to determine the varicose plexuses of small pelvic and dilated ovarian vessels in different positions, the degree of pelvic venous occlusion, blood flow back. pelvic veins to the saphenous veins of the legs and perineum. Normally, the ovarian vessels are not contrasting, and no accumulation of radiopharmaceuticals is observed in the venous plexuses. The pelvic venous occlusion coefficient is calculated to objectively assess the degree of venous occlusion of the small pelvis. However, this method has its drawbacks: invasiveness, relatively low spatial resolution, the inability to accurately determine the diameter of the vessels, so it is not used very often in clinics today.
  • Video laparoscopic examination is a valuable tool in assessing the undiagnosed. Along with other methods, it can help determine the causes of pain and prescribe the right treatment. With varicose veins of small pelvic vessels in the ovarian region, along the round and wide ligaments of the uterus, the vessels can be seen in the form of cyanotic, dilated vessels with thin and tense walls. 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 impossibility of determining reflux through the veins. Currently, the use of this method is diagnostically justified in case of suspicion of multifocal pain. Laparoscopy allows the visualization of the causes of CPP, such as endometriosis or adhesions, in 66% of cases.

Features of therapy

For complete treatment of varicose veins of the small pelvis, a woman should follow all the recommendations of the doctor, as well as make lifestyle changes. First of all, it is necessary to pay attention to the loads, if they are too high, they should be reduced, if the patient leads an excessively sedentary lifestyle, do sports, walk more often, and so on.

Patients with varicose veins are strongly advised to adjust their diet, consume as little harmful foods as possible (fried, smoked, large amounts of sweet, salty, etc. ), alcohol, caffeine. It is better to prefer vegetables and fruits, dairy products, grains.

Also, for the prevention of the development of the disease and for medicinal purposes, doctors prescribe compression underwear for patients with varicose veins.

Medications

ERCT therapy involves several important points:

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

Varicose veins should be carried out in training courses. The rest of the painkillers are only allowed to be drunk during a painful attack. For effective therapy, the doctor often prescribes the following drugs:

  • phleboprotectors;
  • enzyme preparations;
  • drugs that eliminate inflammatory processes in varicose veins;
  • pills to improve blood circulation.

Surgical treatment

Admittedly, conservative treatments give really visible results, especially in the early stages of varicose veins. At the same time, the problem can be solved radically, and the disease can be completely eliminated only with surgery. There are many options for surgical treatment of varicose veins in modern medicine, consider the most common and effective types of surgery:

  • vascular embolization in the ovaries;
  • sclerotherapy;
  • plasticity of uterine ligaments;
  • removal of dilated vessels by laparoscopy;
  • compression of the vessels in the small pelvis with special medical clips (cutting);
  • crossectomy - closure of blood vessels (in addition to the pelvic organs, it is prescribed when the vessels of the lower extremities are affected).

Only symptomatic treatment of varicose veins of small pelvic vessels during pregnancy is possible. Taking phlebotonics on the advice of a vascular surgeon, we recommend wearing compression tights. Phlebosclerosis of varicose veins of the perineum can be performed in the II-III trimester. If there is a high risk of bleeding during a miscarriage due to varicose veins, the choice is in favor of operative delivery.

Physiotherapy

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

  • "Bicycle. "We lie on our backs, put our hands behind our heads or place them across our bodies. Raising our legs, we make circular movements with them, as if pedaling on a bicycle.
  • "The tree. "We sit face to face on any hard, comfortable surface. Lift your legs up and start gently behind your head. Support the lumbar region with your hands and place your elbows on the floor, slowly straighten your legs, lift your body up.
  • "Scissors. "The starting position is at the back. Raise the closed legs slightly above floor level. We spread the lower limbs to the sides, return and repeat.

Possible complications

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

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

Prophylaxis

It is worth following simple prophylactic rules to eliminate varicose veins in the small pelvis as soon as possible and to prevent recurrence of pelvic pathology in the future:

  • do daily gymnastics exercises;
  • prevent constipation;
  • follow a diet that requires plant fiber;
  • do not stay in one position for a long time;
  • take a contrast shower of the perineum;
  • It is better to wear exceptionally comfortable shoes and clothes to avoid the appearance of varicose veins.

Prophylactic measures aimed at reducing the risk of the onset and development of varicose veins in the small pelvis are mainly reduced to the normalization of lifestyle.