Symptomatic pelvic varicose veins: diagnosis and treatment

Symptomatic pelvic varicose veins comprise a distinct and often overlooked clinical entity. They are related to venous insufficiency in one or several pelvic regions. This insufficiency, which has a number of possible causes, is responsible for venous stasis, varicose veins and venous leaks. A diagnosis based on signs and symptoms should lead to transvaginal sonography, which has high predictive value in diagnosing uterovaginal varicose veins. However, there is a high rate of diagnostic error in detecting pelvic varicose veins in other regions. It must be complemented by transperineal ultrasound to search for perineal varicose veins. MRI can reveal associated pelvic disorders. But, like CT scans, its sensitivity is too low to diagnose pelvic varicose veins. Laparoscopy is often used to assess unexplained chronic pelvic pain. A typical semiology of pelvic venous stasis or a suggestive semiology associated with pelvic varicose veins on cross-sectional imaging indicates pelvic phlebography, which is the only procedure that can construct an anatomical and hemodynamic profile of pelvic veins. We report a pretreatment classification of disorders based on venography and intended to help guide therapeutic decision-making. Endovascular treatment, the only possible treatment at present for complex varicoceles and varicose veins supplied by internal afferent iliac vessels, is subject to a careful assessment of contraindications. Depending on the indication, several embolization techniques can be employed, preferably with coils and glue. The long-term results are excellent if the procedure is complete. Pelvic varicose veins, sometimes causing disabling disorders and requiring chronic and expensive medical care, must now be diagnosed and treated.