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

From the article you will learn about the features of varicose veins of the pelvis in women - this is a deformation of the veins of the pelvic region with circulatory disorders of the internal and external genital organs.

General information

In the literature, varicose veins of the pelvis are also referred to as "pelvic congestion syndrome", "varicocele in women", "chronic pelvic pain syndrome". The prevalence of varicose veins in the pelvis increases proportionally with age: from 19. 4% in girls under 17 years of age80% in perimenopausal women, most often the pathology of the pelvic veins during the reproductive period is diagnosed in patients aged 25-45 years.

In the overwhelming majority of cases (80%), varicose vein transformation affects the ovarian veins and is observed extremely rarely (1%) in the veins of the latum ligament of the uterus. According to modern medical approaches, VVMT should not be treated so much from a gynecological, but above all from a phlebological point of view.

Pathological triggers

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

The incidence of pelvic varicose veins is most pronounced in women. This is due to anatomical and physiological features that indicate a tendency to weaken the walls of the veins:

• hormonal fluctuations, including those associated with the menstrual cycle and pregnancy;
• increased pressure in the pelvis, typical of pregnancy;
• Phases of more active filling of the veins with blood, including cyclical menstrual periods, during pregnancy and during sex.

All of these phenomena belong to the category of factors that provoke varicose veins. And they are only found in women. Most patients are confronted with varicose veins of the pelvis during pregnancy, because provoking factors are superimposed at the same time. According to statistics, varicose veins of the pelvis are 7 times less common in men than in the lighter sex. They have a more diverse set of provoking factors:

• hypodynamia - long-term maintenance of little physical activity;
• increased physical activity, especially pulling weights;
• Obesity;
• Lack of sufficient fiber in the diet;
• inflammatory processes in the organs of the genitourinary system;
• sexual dysfunction or clear refusal to have sex.

Genetic predisposition can also lead to pathology of the plexus in the pelvis. According to statistics, varicose veins of the perineum and pelvic organs are most often diagnosed in women whose relatives had this disease. The first changes can be observed in adolescence during puberty.

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

Etiopathogenesis

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

Pelvic venous congestion syndrome may develop due to the congenital absence or insufficiency of venous valves, revealed by anatomical studies in the last century, and modern data confirm it.

It was also found that in 50% of patients, varicose veins are genetic in nature. FOXC2 was one of the first genes identified that played a key role in the development of VVP. Currently, the relationship between the development of the disease and gene mutations (TIE2, NOTCH3), the thrombomodulin level and the transforming growth factor β of type 2 has been determined. These factors contribute to a change in the structure of the valve itself or the vein wall - all this leads to the failure of the valve structure; Enlargement of the vein causing a change in valve function; to progressive reflux and finally to varicose veins.

An important role in the development of the disease can be played by 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 the strength of the veins.

The incidence of VVP is directly proportional to the amount of hormonal changes that are particularly 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 vasodilating effect of progesterone. This venous dilation persists for a month after delivery and can lead to venous valve failure. In addition, during pregnancy, the mass of the uterus increases, its position changes occur, which leads to the expansion of the ovarian veins, followed by venous congestion.

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 postures (sitting or standing) during the work day.

The formation of varicose veins in the pelvis is also facilitated by the anatomical features of the outflow from the veins of the pelvis. The diameter of the ovarian veins is usually 3-4 mm. The long and thin ovarian vein joins the left renal vein on the left and the inferior vena cava on the right. Usually the left renal vein lies 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. 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. A decrease in angle from 39. 3 ± 4, 3 ° to 14. 5 ° results in aorto-mesenteric compression or a nutcracker syndrome. This is what is known as the anterior or true Nutcracker Syndrome, which has the greatest clinical significance. Posterior Nutcracker Syndrome occurs rarely in patients with a retroaortic or annular arrangement of the distal left renal vein. An obstruction of the proximal venous bed leads to an increase in pressure in the renal vein, which leads to the formation of renoovarial 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, more often in women. Currently, with the introduction of radiation and endovascular imaging techniques into practice, this pathology is becoming more and more common.

classification

Varicose veins are divided into the following forms:

• The primary 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 with gynecological pathologies (endometriosis, neoplasms, polycysts).

Varicose veins of the pelvis develop gradually. In medical practice, there are several major stages in the development of the disease. They differ depending on the occurrence of complications and the spread of the disease:

• First degree. Changes in the structure of the ovarian vein valves can be hereditary or acquired. The disease is characterized by an increase in the diameter of the veins up to 5 mm. The left ovary has a pronounced enlargement in the outer parts.
• Second degree. This degree is characterized by the spread of pathologies and damage to the left ovary. The veins in the uterus and right ovary may also be dilated. The expansion diameter reaches 10 mm.
• Third degree. The diameter of the veins increases up to 1 cm, the expansion of the veins is observed equally on 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 primary cause of its development. There is a primary degree, in which the expansion is caused by a dysfunction of the venous valves, and a secondary degree, which is the result of chronic female diseases, inflammatory processes or complications of oncological nature. The degree of the disease can vary depending on the anatomical feature that indicates the location of the vascular disease:

• Intra-caste abundance.
• Vulva and perineal.
• Combined forms.

Symptoms and clinical manifestations

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

• Non-menstrual pain in the lower abdomen. Their intensity depends on the stage of venous damage and the extent of the process. Periodic, mild pain that extends into the lower back is characteristic of the 1st degree of varicose veins of the small pelvis. In later stages, it is felt in the abdomen, perineum, and lower back and is long and intense.
• Profuse slimy discharge. The so-called leucorrhea does not have an unpleasant odor, does not change color, which would indicate an infection. In the second phase of the cycle, the amount of discharge increases.
• Increased symptoms of premenstrual syndrome and dysmenorrhea. Even before the start of menstruation, the pain in women increases, up to the occurrence of walking difficulties. During menstrual bleeding, it can become unbearable and spread to the entire pelvic area, perineum, lower back, and even the thighs.
• Another characteristic sign of varicose veins in the groin area in women is discomfort during sexual intercourse. It can be felt in the vulva and vagina and is characterized as a dull pain. It can be observed at the end of intercourse. In addition, the disease is associated with increased anxiety, irritability, and mood swings.
• As with varicose veins of the pelvis in men, in the female part of patients with such a diagnosis, interest in sex gradually disappears. The cause of the dysfunction is both constant discomfort and a decrease in the production of sex hormones. Infertility can occur in some cases.

Instrumental diagnostics

Diagnosis and treatment of varicose veins is carried out by a phlebologist, a vascular surgeon. Currently, the number of cases of VVP detection has increased due to new technology. 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 other pathologies). Based on the results, an examination by a proctologist, urologist, neurologist and other related specialist is also prescribed.
• If the diagnosis is unclear but VVPT is suspected, ultrasound angioscanning (USAS) of the pelvic veins is performed in the second stage. This is a non-invasive, highly informative method of screening diagnostics that is used in all women with suspected VVPT. If it was previously believed that it was enough to examine only the pelvic organs (vein examination was considered difficult to access and optional), then ultrasound examination of the pelvic veins is now a mandatory examination procedure. With the help of this method, it is possible to determine the presence of varicose veins of the pelvis by measuring the diameter, the speed of blood flow in the veins, and preliminary the leading pathogenetic mechanism - the failure of the ovarian veins or venous obstruction. It is also used to dynamically assess the conservative and surgical management of VVPT.
• Research is carried out transvaginally and transabdominally. The veins of the parametrium, the inguinal plexus and the uterine veins are shown transvaginally. According to various authors, the diameter of the vessels in the above-mentioned locations is 2. 0 to 5. 0 mm (on average 3. 9 ± 0. 5 mm), i. e. H. no more than 5 mm, and the average diameter of the arched veins is 1, 1 ± 0, 4 mm. Veins larger than 5 mm in diameter are considered dilated. The inferior vena cava, the iliac vein, the left renal vein, and the ovarian veins are examined transabdominally in order to exclude thrombotic masses and extravascular 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 is somewhat flattened where it passes over the aorta, but a reduction in its transverse diameter of 2 to 2. 5 times occurs without a significant acceleration in blood flow, resulting in normal outflow without an increase in pressure in thePretenosis ensures zone. With venous stenosis on the background of pathological compression, there is a significant decrease in diameter - by 3. 5 to 4 times and an acceleration in blood flow - over 100 cm / s. The sensitivity and specificity of this method is 78 and, respectively. 100%.
• Examination of the ovarian veins is part of the mandatory examination of the pelvic veins. They are located along the anterior abdominal wall, along the rectus abdominis muscle, slightly to the side of the pelvic veins and arteries. A diameter greater than 5 mm in the presence of retrograde blood flow is considered a sign of ovarian vein failure in USAS. For a full examination, prevention of recurrence and correct treatment tactics, it is necessary to conduct an ultrasound examination of the veins of the lower extremities, perineum, vulva, the inner thigh and buttock area.
• The development of medical technology has led to the use of new diagnostic methods. In the third stage, after the diagnosis is ultrasound, radiation diagnostic methods are used to confirm it.
• Pelvic phlebography with selective bilateral radiopaque ovarcography is one of the radiation-invasive diagnostic methods that is only performed in hospitals. This method has long been regarded as the diagnostic "gold standard" for assessing dilation and for detecting heart valve insufficiency in the pelvic veins. The essence of the method is the introduction of a contrast agent under the control of an X-ray machine through a catheter installed in one of the main veins (jugular, brachial or femoral veins) to the pelvic, renal and ovarian veins. This makes it possible to identify the anatomical variants of the structure of the ovarian veins, to determine the diameter of the gonadal and pelvic veins.
• The retrograde contrasting of the gonadal veins at the level of the Valsalva test serves as a pathognomonic angiographic sign of your valve insufficiency with visualization of a strong expansion or tortuosity. This is the most accurate method of detecting May-Turner syndrome, post-thrombophlebitic changes in the iliac bone and inferior vena cava.
• When the left renal vein is compressed, perirenal venous collaterals with retrograde blood flow into the gonadal veins and contrast medium stagnation in the renal vein are found. The method measures the pressure gradient between the left kidney and the inferior vena cava. Usually it is 1 mm Hg. Art. ; Slope equal to 2 mm Hg. Art. , May suggest slight compression; with a slope >3 mm Hg. Art. Aortomesenteric compression syndrome with hypertension in the left renal vein and a gradient > can be diagnosed5 mm Hg. Art. is considered a hemodynamically significant stenosis of the left renal vein. The determination of the pressure gradient is an important element of diagnostics, because depending on its values, different surgical interventions are planned on the veins of the small pelvis, which is very important under 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 emission computed tomography of the pelvic veins with erythrocytes marked in vitro. It is characterized by the deposition of marked erythrocytes in the pelvic veins and the visualization of the gonadal veins, allows the identification of varicose veins of the small pelvis and dilated ovarian veins in different positions, the degree of pelvic vein congestion, the return of blood from the pelvic veins to the saphenous veins of the legsand the perineum. Usually the ovarian veins are not contrasted, the accumulation of the radiopharmaceutical in the venous plexus is not observed. For an objective assessment of the degree of venous congestion in the small pelvis, the coefficient of venous congestion in the pelvis is calculated. However, this method also has disadvantages: invasiveness, relatively low spatial resolution, the impossibility of accurately determining the diameter of the veins, therefore it is not so widely used in clinics at the moment.
• Laparoscopic video examination is a valuable tool in assessing the undiagnosed. Combined with other methods, it can help identify the causes of pain and prescribe the right treatment. With varicose veins of the small pelvis in the ovarian region, along the round and wide ligaments of the uterus, veins can be visualized in the form of cyanotic, dilated vessels with a thinned and tense wall. The following factors significantly limit the use of this method: the presence of retroperitoneal adipose tissue, the ability to assess varicose veins in a limited area, and the impossibility of determining reflux through the veins. At present, the use of this method is diagnostically justified if multifocal pain is suspected. In 66% of cases, laparoscopy enables the causes of CPP to be visualized, for example endometrial foci or adhesions.

Features of therapy

For the full treatment of pelvic varicose veins, a woman needs to follow all the recommendations of the doctor, and also change her lifestyle. First of all, you need to pay attention to the loads, if they are too high, they need to be reduced, if the patient leads an excessively sedentary lifestyle, engages in sports, walks more often, etc.

Patients with varicose veins are strongly advised to change their diet to consume as little junk food as possible (fried, smoked, in large quantities sweet, salty, etc. ), alcohol, caffeine. It is better to give preference to vegetables and fruits, dairy products and cereals.

Doctors also prescribe patients with varicose veins to wear compression garments for prophylaxis of the course of the disease and for medical purposes.

Medication

The ERCT therapy includes several important points:

• getting rid of the reflux of venous blood;
• Relieving the symptoms of the disease;
• Stabilization of vascular tone;
• improved blood flow to the tissue.

Preparations for varicose veins should be done in courses. The rest of the drugs, which play the role of pain relievers, are allowed to be drunk only during a painful attack. For effective therapy, the doctor often prescribes the following drugs:

• Phleboprotectors;
• Enzyme preparations;
• drugs that relieve inflammatory processes with varicose veins;
• Tablets to improve blood circulation.

Operative treatment

It is worth noting that conservative methods of treatment give really visible results, especially in the initial stages of varicose veins. At the same time, the problem can be fundamentally resolved, and the disease can be completely eliminated only through surgery. In modern medicine, there are many variations of the surgical treatment of varicose veins. Consider the most common and effective types of operations:

• Embolization of veins in the ovaries;
• Sclerotherapy;
• plastic of the uterine ligaments;
• Removal of enlarged veins by laparoscopy;
• Clipping of veins in the small pelvis with special medical clips (clipping);
• Crossctomy - venous ligation (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 pelvis is possible. We recommend wearing compression tights and taking phlebotonic drugs on the recommendation of a vascular surgeon. In the II-III trimester, phlebosclerosis of the varicose veins of the perineum can be performed. If there is a high risk of bleeding during spontaneous delivery due to varicose veins, the choice is made in favor of a surgical delivery.

physical therapy

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

• "Bicycle". We lie on our back, throw our hands behind our heads or place them along the body. We lift our legs and make circular movements with them, as if we were stepping on a bicycle.
• "Birch". We sit face up on any hard, comfortable surface. Lift your legs up and gently start them behind your head. Support your lumbar region with your hands and put your elbows on the floor, slowly straightening your legs and lifting your body up.
• "Scissors". The starting position is on the back. Raise your closed legs slightly off the floor. We spread the lower limbs to the sides, bring them back and repeat the process.

Possible complications

Why are pelvic varicose veins dangerous? The following consequences of illness 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 quickly as possible and the pathology of the pelvic organs not to recur in the future, it is worth following simple preventive rules:

• perform gymnastic exercises daily;
• Prevent constipation;
• observe a nutritional scheme, which must include vegetable fiber;
• do not stay long in one position;
• take a contrast shower of the perineum;
• So that varicose veins do not appear, it is better to wear particularly comfortable shoes and clothes.

Preventive measures to reduce the risk of the development and progression of varicose veins in the pelvis are mainly limited to the normalization of lifestyle.