The Importance of Pelvic Vein Diseases
The importance of pelvic venous disorders (PeVD) has been increasingly recognized. However, progress has been hampered by historical syndromic nomenclature, confusing the interrelationship of many pelvic symptoms and their underlying pathophysiology.
A valid classification instrument defining homogenous patient populations is crucial for clinical communication, interpretation of the literature, and development of appropriate clinical trials. The Symptoms-Varices-Pathophysiology (SVP) classification for PeVD is one such instrument.
Varicose Veins of the Pelvic Region
Varicose veins, which have a bulging and twisted appearance, occur when vein valves malfunction and allow blood to accumulate in the vein. They can occur anywhere in the body, but are most common in the legs and feet.
Pelvic varicose veins, also known as pelvic congestion syndrome (PCS), can cause pain and discomfort in the groin area and lower abdomen, particularly when standing or sitting for long periods of time. Women with PCS often feel a dull pain or heaviness in the pelvic region, which can increase during pregnancy and after sexual activity.
Like varicose veins in the legs and feet, PCS is caused by a malfunctioning of the vein valves. This results in the blood flowing backward into the pelvic veins resulting in engorgement and pain. This condition is exacerbated by the presence of a varicose urethra, and it can be confirmed using ultrasound imaging, venography or MRI [50]. Treatment for PCS is via minimally invasive surgical procedure called pelvic vein embolization (PVE) which targets and closes the affected varicose veins in the groin, vulva and peri-urethral regions.
Extrapelvic Varices
Patients may present with pain rated eight out of 10 on the VAS that is worse with standing, walking, and intercourse. The patient may also have a history of left ovarian vein reflux, or she may have had a prior sclerotherapy procedure.
The symptoms (S) and signs of varices (V) are associated with PeVD in 4 anatomic zones extending in a descending fashion from the renal veins to the lower extremities. Zone 1 comprises the left renal vein, the gonadal, and internal iliac veins and their pelvic venous plexuses. Zone 2 comprises the abdominal and iliac sacro-vaginal veins and their tributaries. Zone 3 comprises the pelvic origin extrapelvic transitional veins that reflux through the pelvic escape points to the genitalia and lower extremities.
Increased venous pressures resulting from either proximal reflux or obstruction are transmitted to these reservoirs and develop the characteristic visible varicosities that extend typically over the posteromedial thigh. This phenotype is designated V3. Ideally, these are differentiated from refluxing pelvic-origin lower extremity varices by concurrent use of the CEAP classification system.
Renal Hilar Varices
The renal veins course in front of the aorta and drain into the inferior vena cava. Anomalies of the renal veins include varices at the hilar level (nutcracker phenomenon), which may be asymptomatic or cause hematuria. These varicosities occur when the left inferior phrenic and posterior segmental kidney arteries entrap and compress the left renal vein (LRV). For more details please visit nexaalgo.com
Compression of this area is due to mesoaortic pressure gradients created by the superior mesenteric artery (SMA) invading the aortic arch and surrounding the left inferior phrenic venous loop. The pressure gradient persists in supine and prone positions, but disappears with the patient leaning forward (Figure 7).
Wendel et al have described three cases of symptomatic nutcracker syndrome relieved by dissection of a fibrous tunnel between the SMA and the aorta, which had indented the LRV. This procedure avoids the complexity and thrombotic risk of direct renocaval reimplantation, and it eliminates the pressure gradient. This condition should be considered whenever a patient with hematuria has a distended hilar LRV.
Sciatic/Tibial Nerve Varices
The tibial nerve supplies the skin of the lower half back of the leg and part of the foot (Fig 3). Incompetent veins originating in the pelvic nonsaphenous trunks can develop in the posteromedial thigh and can cause localized symptoms. These varicosities are associated with pain, discomfort, tenderness, itching and superficial venous thrombosis.
Often these veins are in the form of a tortuous structure encased inside the nerve epineurium. They can enlarge with reflux, causing itching and heaviness of the limb. Incompetent tibial nerve veins can also occur in the distribution of calf varicosities.
A variation of this phenomenon was originally described by Verneuil1 in 1890 and later by L. Thiery2 in a short article in the French journal ‘Phlebologie’ in 1988. This is the so-called sciatic nerve varicosity (SNV). Ultrasound demonstrates dilated veins originating in the lateral pelvic wall and demonstrating reflux at rest involving the named saphenous and accessory saphenous trunks and their tributaries.
