SONOWORLD : Pelvic varices

Pelvic varices: "Pelvic varices in women consist of tortuous and dilated parauterine veins [in the broad ligament] and ovarian veins. They are often bilateral. Concomitant paravaginal, pelvic sidewall and internal iliac varicosities may also be present. Occasionally, pelvic varices may communicate with vulvar and lower extremity varices. There may also be associated ovarian vein reflux.

Pelvic varices may occur due to various causes, a few of which include thin-walled and unsupported structure of the veins, the presence of few valves, multi-parous state, gravity and prolonged upright position. Overall they mostly represent a late complication of pregnancy.

Classification- Pelvic varices may be
1.Primary –
• Occurs de novo, without any underlying pathology.
•They are responsible for causing the pelvic congestion syndrome and cause chronic pelvic pain.
2.Secondary –
• Occurs due to some underlying organic pathologies such as endometriosis, pelvic inflammatory disease, leiomyoma, large pelvic tumors.
• Are usually painless.

Clinical presentation – Most of the patients are in the reproductive age group; they may be completely asymptomatic, present with non-specific chronic pelvic pain [15-20%], or present with the ‘pelvic congestion syndrome’, characterized by symptoms of congestive dysmennorhea, dyspareunia or urinary complaints. Pregnancy and postpartum period may aggravate the condition. Thrombosed varicose veins especially in the round ligament may simulate an inguinal hernia.

Associations – Pelvic varices may be associated with ovarian, vaginal and vulvar varices. Secondary varices are associated with pathologies described above.

Imaging appearance – Ultrasound, CT and MRI all have been used to diagnose pelvic varices non-invasively. The gold standard has been venography, but is now ultrasound.
Ultrasound features:
• The pelvic varices may be seen as long, tubular, hypoechoic tortuous structures in the adnexae.
• These may extend laterally in the broad ligament upto the pelvic side wall and inferiorly may extend into the paravaginal venous plexus.
• If thrombosed, echogenic material may be seen within these tortuous structures.
• On color Doppler imaging, these varices completely fill with color.

Differential diagnosis – the following may be considered:
1. Cystic adnexal masses – the absence of color within the masses differentiates them from varices.

Management- Transcatheter embolization involving venous embolization or ovarian vein excision and / or sclerotherapy of the involved veins after control of the intrapelvic reflux, are the treatment options available.