Pelvic Vein Insufficiency

Insufficiency within the pelvic veins although a proven clinical entity, is not commonly assessed and is often overlooked and underdiagnosed in women. Insufficiency of the pelvic veins, otherwise known as pelvic congestion syndrome in women, and varicocele in men, can be the cause of increased pain and discomfort for the patient. Insufficiency within the gonadal veins can, when prolonged, lead to an increase in varicose veins within the lower extremities, or in the instance of a patient who has already undergone surgery, these veins may be a strong contributor to recurrence rates. By comparing the similarities between male and female insufficiency, a standardised and more common practice of diagnosing female insufficiency should be implemented. The overall treatment and outcome for the patient, not to mention the long term benefits, especially if leg varicosities are involved as well, will be significantly improved if this condition is diagnosed correctly.

Clinical indications

Patients with pelvic insufficiency typically have varied symptoms that are nonspecific that makes diagnosis difficult. Symptoms generally relate to abdominal pains within the left iliac fossa, flanks and hypochondrium, positional pains (occasionally worse when lying down on affected side), cyclical discomfort (often worst shortly before menstruation), during and post-coital pains and urinary symptoms such as infections, hydronephrosis, pyelonephritis, renal colic and frank haematuria.

Noticeable varicose veins in the pelvic region are common, particularly in pregnant women, however, commonly go unrecognized. Vulval and peri-vulval veins will often become dilated and distended during pregnancy; however, these will generally return to normal after delivery. In women who have subsequent pregnancies, these veins undergo continued stress and as a result will become more prominent. Obvious peri-vulval varicose veins can be seen to extend over the buttock and down the back of the thigh, whilst vulval dilated veins can be clearly seen medially in the upper thigh.

Diagnostic Testing

In an ideal setting, it is preferable to assess for pelvic insufficiency by locating and examining the left and right ovarian veins cranially to caudal. Ideally, if the patient is fasted, bowel motility and bowel gas are reduced, enabling a clearer image. It is preferable to start by using transverse sections in the upper aspect of the abdomen and identify the aorta and superior mesenteric artery (SMA).The ideal window is through the left lobe of the liver and pancreas. Here, the left renal vein should be seen coursing in-between the SMA and aorta. Following the left renal vein to approximately half way along its length to where the left ovarian vein should join. If incompetent, the vein is generally easily seen. Consider the transverse aorta as a clock face; in this plane, the ovarian vein should lay at the three o'clock position, and by turning the probe longitudinally, the left ovarian vein is able to be followed inferiorly. It is essential to ensure that the left ovarian vein joins the left renal vein.

Image Above: A 22-year old with evidence of compression of the left renal vein in-between the SMA and aorta suggestive of nutcracker syndrome.

Treatments for both male and female varicoceles

Endovascular treatments are generally the most common method performed for both men and women. Vein embolisation techniques with the use of coils as well as sclerosants are also proven to be a successful and provide long term benefits. A guide wire is passed through the right femoral vein, or jugular vein, and advanced into the affected vein. Sclerosant is then injected slowly with the patient holding their breath and performing a Valsalva manoeuvre. The most common sclerosant used is sodium tetradecyl sulfate and polidocanol, although there are a large number of sclerosants available. The combination of external compression may also be used during the sclerosant injection, particularly in men to avoid the sclerosant passing into the scrotum. Complications are rare and will generally be related to thrombophlebitis or in the event of the wrong sized coil, pulmonary embolisation. The risk of perforation has in recent times been diminished with the use of hydrophilic wires and microcatheters.

Tamara’s full published article can be found in the Australasian Sonographers Association’s prestigious peer-reviewed journal - SoundEffects.