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Vulval phlebography in the pelvic congestion syndrome
Clin. RadioL (1974)25, 517-525
VULVAL
PHLEBOGRAPHY IN THE SYNDROME
PELVIC
CONGESTION
OSCAR CRAIG and JOHN T. HOBBS
St Mary's Hospital, London, W.2, and Bolingbroke Hospital, London, S.W.11 Twelve patients referred to a general surgeon with special interest in varicose veins were found to have vulval varices. All the patients were considered to be suffering from the pelvic congestion syndrome. Their radiological investigation by percutaneous vulval phlebography is described. It is suggested that patients with vulval varices should be examined radiologically by percutaneous vulval vein injection of contrast medium. It is postulated that pelvic vein thrombosis may precipitate the pelvic congestion syndrome. Whereas there is no established treatment of this syndrome, the radiological examination has proved helpful in planning the treatment of these patients. PATIENTS with the pelvic congestion syndrome may lished by many investigators (Taylor, 1949; Allen present with varying symptoms including backache, and Masters, 1955; Alien, 1971). In the original vague feelings of pelvic discomfort, worse before papers on this condition radiological examinations and during the menstrual period, dysmenorrhoea, were not performed. Subsequently, methods to menorrhagia and dyspareunia. Some cases of investigate the pelvic veins were described. These recurrent 'cystitis', with negative bacteriological include, uterine phlebography (Guillem et al., 1951 ; examination and normal urography should be Kauppila et al., 1971; Chidekel and Edlundh, included in this syndrome. Peripheral venous 1968; Hughes and Curtis, 1962), renal phlebodisorders, vulval varicosities, thigh and leg varices, graphy and ovarian phlebography (Chidekel, 1968), swelling and discomfort in a limb may be the main trans-osseous phlebography (Guillem and Baux, presenting features. Thus patients may present to 1954), and cannulation of vulval varices (Lea the gynaecologist with predominant pelvic symp- Thomas et al., 1967). It is the purpose of this toms, to the general surgeon with leg varicosities paper to describe the investigation of 12 patients, and vulval veins or to the urologist with frequency all of whom had vulval varices. All the patients were considered to be suffering from manifestations and urgency of micturition. Dixon and Mitchell (1970) stated that varicose of the pelvic congestion syndrome. As these veins of the vulva are common, troublesome and patients were referred by a general surgeon, most ill understood. They found that 20 ~ of women also had symptoms and signs of peripheral venous developed varicosities during pregnancy and one disorders, but a few had trivial or no symptoms in three of these showed vulval involvement. Dodd referable to the legs. It is believed that radiological and Payling-Wright (1959) found that 8 % of women examination of these patients with vulval varicosibooked for antenatal care were referred to the ties is important. The peripheral leg varices may varicose vein clinic; 80 patients from a total of communicate with the vulval and pelvic veins 4267 booked for antenatal care had distressing and also the presence of pelvic varicosities may vulval varices, i.e. an incidence of 2 %. It is said explain the many pelvic symptoms about which that most of the vulval veins seen during pregnancy these patients complain. The pelvic veins were disappear following parturition. The patients in examined radiologically by percutaneous puncture this series had their last pregnancy many years of vulval varicosities. Table 1 lists the patients, their main symptoms, beforehand, with one exception when the time interval was one year. They were referred to a general clinical features and radiological findings. The surgeon with an interest in varicose veins. From a radiological appearances are seen in Figs. 1 to 7 series of 4000 patients with peripheral varicosities 40 were found to have vulval involvement, i.e. an TECHNIQUE OF EXAMINATION incidence of 1%. In all the cases reported in this series percuAn association between the pelvic congestion syndrome and pelvic varicosities has been estab- taneous puncture of a vulval vein was performed. 517
518
C L I N I C A L RADIOLOGY
It was not found necessary as in the series reported by Lea Thomas et al. (1967) to expose a vein for cannulation. A small butterfly needle (gauge 21) was inserted into a vulval vein and strapped in position. In some cases it was necessary to insert the needle with the patient standing, because the veins were not visible in the recumbent position. In these cases great care was necessary while moving the patient to a supine position, to avoid displacing the needle. Patency of the needle was maintained by gentle saline infusion. A small quantity of contrast medium was injected and observed on the television screen. I f satisfactory venous filling was obtained then 20-30 ml of Urografin 60 were injected and serial films were taken using a hand changer. Four or five 35 cm 2 films were usuMly sufficient. The direction of flow was observed on the television monitor and this direction was recorded by suitable timing of the film series. The patency of the needle was maintained by saline infusion until the films had been viewed. I f necessary a further injection was made and a second series taken. A 40 degrees oblique supine film was found t o be the most satisfactory for visualising the pelvic veins. This had been noted by Lea Thomas et al. in their series. It is important at the completion of the examination to infuse sufficient saline to clear the varices of contrast, to minimise the risk of phlebitis. When contrast lingers in the varices or if the needle becomes displaced, then vulval massage is advisable to encourage venous flow. The patients have all attended as out-patients, and no premedication has been found necessary in those patients examined so far. The examination can be completed within 15 minutes of a satisfactory venepuncture.
(d) Visualisation or otherwise of the internal iliac vein. It was clear that all the cases with peripheral leg varicosities demonstrated a communication with the saphenous or femoral veins via the superficial or deep external pudendal veins, and reflux of contrast down the leg was common in most of these. The cases with the more severe pelvic symptoms had the most marked pelvic varicosities. Varicosities in the vesical plexus were associated with the 'irritable bladder syndrome'. Those patients with dyspareunia had varicosities of the vesical plexus, pudendal vein or broad ligament varicosities. Only five of the 12 cases examined showed filling of the internal iliac vein. This could not however be taken, as definite evidence of occlusion of the internal iliac vein. The findings on vulval phlebography would indicate that there is some merit in the investigation of patients with vulval varices: The general surgeon treating peripheral leg veins should examine carefully for vulval involvement. O f ten cases examined by Dixon and Mitchell (1970) eight had communications with the saphenous system, and
DISCUSSION All the patients had vulval varicosities. The clinical features could be divided into three main groups. (a) Vulval varicosities, pelvic symptoms and peripheral leg varices, six cases (Table 2)_ (b) Vulval varices and peripheral leg symptoms only, two cases (Table 3). (c) Vulval varices and pelvic symptoms only, 4 cases (Table 4). In all, there were four main radiological findings : (a) Varicose pelvic veins. (b) Altered flow routes. (c) Communication with the peripheral leg veins.
FIG. 1 Case 1. - Pudendal vein filling (1). Utero-vaginal varices (2). Internal iliac vein (3).
VULVAL PtlLEBOGRAPHY
IN THE P E L V I C C O N G E S T I O N S Y N D R O M E
519
F~G. 2 Case 2. - Vulval varices (l). Obturator vein (2). Ascending lumbar vein (3). Presacral vein (4). N o internal iliae vein filling.
F~a. 3 Case 3. - Bilateral vulval varices (I). Obturator vein (2). Vesical plexus varices (3). N o internal iliac vein filling.
Fie. 4 Case 4. - Vulval varices (1). Internal pudendal vein varicose (2). External iliac vein (3), filling via superficial external pudendal vein. N o internal iliac vein filling,
F~G_ 5 Case 5. - Vulval varices (1)_ Pudendal vein varicosities (2). Obturator vein (3). Internal iliac vein (4).
520
CLINICAL
RADIOLOGY
FIG. 6 Case 7. - Enlargement o f vulval varices (1), with bilateral filling and contralateral flow to obturator vein (2).
, FIG. 7 Case 11. - Vulval veins (1). F e m o r a l vein (2). Varicose vesical veins (3). External iliac vein (4).
two had varices originating from the gluteal region. These authors also advocated direct vulval injections radiologically. Gyneacologists should also investigate patients with vulval veins and symptoms of the pelvic congestion syndrome. Many of these patients have vague symptoms of pelvic discomfort, menorrhagia and dysmenorrhea which are unexplained. Dyspareunia can be sufficiently severe as to lead to marital distress and psychiatric help may be sought. Recurrent bladder symptoms which present to the urologist and have negative excretion urography and negative bacteriological examinations are common. A search should be made for vulval veins which in these cases may be associated with vesical plexus varicosities. In patients with the pelvic congestion syndrome, apart from the presence of vulval varices, physical examination may be very disappointing. Allen and Masters (1955) described tenderness of the cervix which may be excessively mobile and which they termed the 'universal joint cervix'. This is not an impressive clinical sign. It is important that in looking for varices the patient should be examined standing. Quite marked vulval varices may not be visible when the patient is examined supine. Chidekel (1968) said that the precise cause for the occurrence of pelvic varicosities in women is not clear and Guillem et al. noted that very little attention has been paid to pelvic varicosities in gynaecological diagnosis. It has been suggested that pregnancy may produce pelvic venous compression and secondary incompetence of pelvic veins (Kaupilla et al., 1971; Chidekel and Edlundh, 1968), and certainly the pelvic congestion syndrome has been
described mostly in multiparous patients. There is often a history of pelvic complications relating to one pregnancy, following which these symptoms developed and in the patients in this series the occurrence of vulval varices could all be related to a particular pregnancy. Although entirely speculative it is suggested that thrombosis of the internal iliac vein or some of its tributaries might well produce this syndrome. There was filling of the internal iliac vein in five of these 12 patients and no thrombi were visualised. However the cases were all examined many years following the onset of symptoms. The pattern of the pelvic veins varied greatly from case to case, but the flow routes were altered and also varied in each case. It would be possible for thrombosed areas to exist in internal iliac vein tributaries and not be visualised. Murray and Comparato (1968) noted that in 31 patients examined by uterine phlebography, a filling defect was seen in the ovarian or uterine veins of one or both sides. These authors also thought that uterine phlebography was the only method short of surgical means that confirms a diagnosi s of the pelvic congestion syndrome. The methods for examining the pelvic veins include the trans-uterine route, the trans-osseous route and renal vein and ovarian catheterisation. By these routes not all the visceral veins are visualised and vulval varices may not be filled. Abnormal flow routes may not be seen, and communications with peripheral leg varicosities will not be outlined. Although cannulation of vulvavarices by surgical exposure has been described, it is suggested that percutaneous puncture of vulval varices is a more satisfactory, less time
V U L V A L P H L E B O G R A P H Y IN THE P E L V I C C O N G E S T I O N SYNDROME
521
TABLE 1
Pt.
Age
Presenting complaint
R.W. 1
42
Varicose veins both legs for 22 years, worse during periods. Vulval veins ruptured during second pregnancy_
N.W.
2
3_L.
3
30
Pregnancies
Clinicalexamination
Radiology
Varicose veins both legs. Large vein on left thigh controlled by compressing vulval veins.
1. Vulval filling. Contrast passed from vulval veins to saphenous vein and down leg. Also to pelvis via obturator and internal pudendal vein. Utero-vaginal varicosities, Interna/ iliac vein filling high in pelvis. 2. Ascending phlebography normal external iliac vein.
Varicose veins both legs. Aching vulval varices. History of heavy feeling in pelvis. Bilateral oophorectomy for small ovarian cysts, Abdominal discomfort persisted.
Large superficial varices thighs and lower legs. Vulval varices, worse on right side.
1. Vulval phlebogram. Vulval varices. Obturator vein filling. No internal iliac vein filling. Ascending lumbar and pre-sacral vein filled. Large varicose internal pudendal vein. 2. Ascending phlebogram - block of popliteal vein and lower femoral vein. External iliac vein patent.
Severe pains in vulval area for four years, worse before and during menses. Dyspareunia, pelvic discomfort.
Large vein extending from left labium major to perineum. Trivial veins both lower legs.
1. Vulval phlebogram. Filling of vulval varices, obturator and pudendal veins on contralateral side. Vesical plexus varices on both sides_ No internal iliac vein filling. 2. Ascending phlebogram. Normal external iliac vein.
2
522
CLINICAL RADIOLOGY
TABLE 1 (contd.)
Clinical examination
Radio logy
Varicose veins for 20 years. Recently worse before and during periods. Last two pregnancies complicated by thrombophlebitis_ Discomfort in pelvis and vulval varices.
Varicose veins both legs. Large vein on medial aspect of left thigh communicatifig with posterior part of labium major.
Vulval phlebogram_ Vulval varices on both sides. La ge internal pudendal vein filling vesical varices. Contrast passing via superficia external pudendal vein to external iliac vein and also dow the leg. No internal i filling.
Vulval veins. Feeling of pelvic pressure worse during periods. Legs ache during periods.
Trivial veins in both lower limbs. A group of veins on upper medial aspect of thigh, not related to sapheno-femoral junction.
Vulval phlebogram. Contrast )assed to thigh vessels and also via obturator vein to internal iliac vein high in the penis. Dilated internal pudendal vein and uterc ginal varices.
Vulval varices. Pelvic discomfort worse during and before periods. Dyspareunia severe. Recurrent 'cystitis' with negative urology.
Vulval varices. Trivial leg varices.
Vulval phlebogram. Varicose ,rnal pudendal vein and vulval varices. Filling of intern~ iliac vein. Communication with saphenous and femoral vein in thigh and contrast ~assing to external iliac system.
Pt.
Age
Presenting complaint
M.M. 4
37
S,P. 5
3l
J.K, 6
45
Pregnancies
V U L V A L P H L E B O G R A P H Y IN THE P E L V I C C O N G E S T I O N SYNDROME
523
TABLE 1 (contd.)
Clinical examination
Radiology
"Vulval heaviness most marked after coitus. Vulval varices 12 years. Since last pregnancy, thigh varices - legs ache during menses.
Large vulval varices. Superficial thigh varices communicating with vulval varices.
Yulval varices communicating with thigh varices. Obturator vein filling and upper part of internal iliae vein filled_ Some contrast passing to contralateral side. Contrast also passing to femoral vein in thigh.
32
Vulval varices since last pregnancy one year ago, but varicose veins in legs for eight years and legs ache particularly during menses.
Veins on medial sides of both thighs, which communicate with the vulval veins.
Vein high in left thigh injected, Vulval veins filled, but also contrast passed to femoral vein and retrogradely down the leg. Poor obturator filling, but vesical veins filling from the internal pudendal system. Bilateral pelvic filling from left side. No filling of internal iliac vein, external iliac vein normal.
38
Yulval varices since second pregnancy. Dyspareunia and fullness in vulva persisting until following day after coitus, 'irritable' bladder_ Peristent fullness in both legs.
Left vulval veins.
Left vulval vein injected. Contrast passed down leg to femoral vein and into normal external iliea vein. Filling of vulval varices, pelvic veins irregular and broad ligament varices filled.
Pt.
Age
Presenting complaint
M.P. 10
39
C.A. 11
M.A. 12
Pregnancws
CLINICAL RADIOLOGY
524
TABLE 1 (contd.) Pt.
Age
Presenting complaint
P,Y.
Clinical examination
Radiology
51
Varicose veins right leg 33 years, left leg ten years. Right leg heavy and painful especially before and during periods. Veins injected in right leg 1944 and 1958. Long saphenous on right stripped 1957. Vulval varices worse after second pregnancy in 1954.
Varicose veins both legs. Thigh veins on the right communicate with the posterior vulval veins.
Right vulval phlebogram. Contrast passed to femoral vein via deep external pudendal vein. Large vulval varices filled. Obturator vein filling and internal iliac vein filled. No vesical or para-uterine veins filled. Contralateral vulval veins and obturator veins filled.
M.L. 8
34
Varicose veins both legs 13 years. Pelvic pain and dyspareunia relieved by hysterectomy. Urgency of micturition persists.
Varicose veins both legs mainly inner aspects of thighs. Vulval varices most marked on the left side.
Left vulval phlebogram. Contrast passed to femoral vein. Vulval varices filled. Obturator filling but no internal iliac filling. Contrast passed to contralateral obturator vein. Varicose vesical plexus.
R,P,
45
Bilateral varicose veins 19 years, worse following groin ligations. Pelvic pain and 'cystitis'. Vulval varicosities after first pregnancy, subsequently getting worse.
Bilateral varicose veins. Long saphenous vein on both sides communicates with vulval varices.
Vulval varices injected. Contrast passed down leg to superficial varices and then to femoral vein. Filling of external iliac system. No filling of internal iliac vein.
7
9
Pregnancies
consuming procedure, which can be p e r f o r m e d as a purely radiological technique o n an out-patient basis. By this route, the vulval veins, the visceral pelvic veins, a b n o r m a l flow routes a n d peripheral leg varices can be seen. A l t h o u g h this radiological e x a m i n a t i o n has a p a r t to p l a y in explaining the patients' s y m p t o matology, it is also a d v o c a t e d as influencing the treatment. Pelvic a n d vulval c o m m u n i c a t i o n s should be dealt with surgically if they are seen to c o m m u n i c a t e with the p e r i p h e r a l leg veins. S a p h e n o - f e m o r a l ligation a n d / o r vein stripping will be insufficient for leg varices in these cases. D i x o n a n d Mitchell a d v o c a t e d four points of o p e r a t i o n in these patients, (1) internal p u d e n d a l vein, (2) o b t u r a t o r vein, (3) r o u n d ligament veins, (4) greater saphenous tributaries, i.e. superficial and deep external p u d e n d a l veins. A p p r o p r i a t e surgical exposures were described. In the pelvic congestion s y n d r o m e g o o d results have been recorded following h y s t e r e c t o m y and
this m a y be explained b y the reduction in pelvic b l o o d flow following arterial and venous ligation.
Acknowledgements. - We wish to thank Dr Cardew and the staff of the Audio-Visual Communication Department of St Mary's Hospital Medical School for the prints of the X-rays. We also wish to acknowledge the helpful criticism and advice given by Dr Ian Isherwood in the preparation of this paper.
REFERENCES ALLEN, W. M. & MASTERS, W. H. (1955). Traumatic laceration of uterine support. American Journal of Obstetrics and Gynaecology, 70, 500-513. ALLEN, W. M. (1971). Chronic pelvic congestion and pelvic pain. American Journal of Obstetrics and Gynaecology, 100 (2), 198-202. CHID~EL, N- & EI~LUNDH, K. O. (1968). Trans-uterine phlebography with particular reference to pelvic varicosities. Acta Radiologica (Diagnosis), 7, 1-ll.
525
VULVAL P H L E B O G R A P H Y IN THE PELVIC CONGESTION SYNDROME TABLE 2
TABLE 4
CASES WITH PELVIC CONGESTIONSYNDROME, VULVAL
CASES WITH VULVAL VARICES AND PELVIC SYMPTOMS
VARICES AND PERIPHERAL VARICOSITIES
Symptoms Symptoms
Radiology
l
Pelvic discomfort Leg varices
Internal pudendal veins Utero-vaginal varicosities Internal lilac filling Saphenous filling
2
Pelvic discomfort Leg varices
Varicose internal pudendal vein No internal iliac filling Block popliteal vein
4
Pelvic discomfort Leg varices
Varicose internal pudendal veins No internal iliac filling Superficial external pudendal vein to external lilac and leg veins
Pelvic discomfort Dyspareunia Urgency of micturition Leg varices
Varicose vesical plexus Obturator vein filling No internal ifiac filling Femoral vein filling
Pelvic discomfort Urgency of micturtion Leg varices
No filling of internal iliac vein Femoral vein filling
Vulval discomfort especially after coitus Leg varices
Obturator vein filling Internal iliac vein filling Femoral vein filling
10
TABLE 3 CASES WITH VULVAL VARICES AND LEG SYMPTOMS ONLY
Symptoms 7
34
Radiology
Bilateral varicose veins Vulval veins Worse during menses
Obturator vein filling Internal iliac vein filled Femoral vein filling
Leg varices ache during menses
Obturator vein filling Vesical varices Bilateral pelvic vein filling No internal iliac vein filled
12
Radiology
Vulval pain worse during menses Dyspareunia
Obturator vein. Contralateral Pudendal vein. Contralateral Vesical varices No internal iliac filling
Pelvic pressure worse during menses
Obturator vein Internal pudendal vein Utero-vaginal varices Filling of internal iliac vein
Pelvic discomfort worse during menses Dyspareunia Urgency of micturition
Internal pudendal varices Filling of intei:nal lilac vein
Vulval discomfort Dyspareunia Irritable bladder
Broad ligament varices Some contract to external iliac vein No internal iliac filling
CHIDEKEL, N. (1968). Renal phlebography in female pelvic varicosities. Acta Radiologica (Diagnosis), 7, 193-209, DODD, H. & PAX'LING-WRIGHT,H. (1959). Vulval varicose veins in pregnancy. British Medical Journal, 1, 831-832. GUILLEM, P., BAUX, R., VOlSlN, R. & PAILLE, J. (1951). La phlebographie pelvienne par vole uterine_ Gynaecologie et Obstetrique, Supplement Bulletin de l'Association des Gynaecologues et Obstetriques de Langue Franfaise, 4, 709-713. GUILLEM,P. & BAUX, R. (1954). La PhlebographiePelvienne. Masson et Cie, Paris. HUGHES, R. R. & CURTIS, D_ D. (1962). Uterine phlebography. American Journal of Obstetrics and Gynaecology, 83, 156-164. KAUPILLA, A., JARVINEN, P. A. & VUORINEN, P. (1971). Improve visualisation in uterine phlebography. British Journal of Radiology, 44, 284-289, LEA THOMAS, M., FLETCHER,'E. W. L., ANORESS, M. R- & COCKETT, F. B. (1967). The venous connections of vulval varices, ClinicalRadiology, 18, 313-317. MURRAY, E. & COMEARATO,M. (1968). Uterine phlebography, American Journal of Obstetrics and Gyneacology, 102, 1088-1093. TAYLOR, H. C. (1949). Vascular congestion and hyperemia. American Journal of Obstetrics and Gynaecology, .57 (2), 211-227, 637-653,654-668. DtxoN, J. A. & MITCHELL, W. A. (1970). Venographic and surgical observations in vulval varicose veins. Surgery, Gynaecology and Obstetrics, 131,458-464.
VULVAL
PHLEBOGRAPHY IN THE SYNDROME
PELVIC
CONGESTION
OSCAR CRAIG and JOHN T. HOBBS
St Mary's Hospital, London, W.2, and Bolingbroke Hospital, London, S.W.11 Twelve patients referred to a general surgeon with special interest in varicose veins were found to have vulval varices. All the patients were considered to be suffering from the pelvic congestion syndrome. Their radiological investigation by percutaneous vulval phlebography is described. It is suggested that patients with vulval varices should be examined radiologically by percutaneous vulval vein injection of contrast medium. It is postulated that pelvic vein thrombosis may precipitate the pelvic congestion syndrome. Whereas there is no established treatment of this syndrome, the radiological examination has proved helpful in planning the treatment of these patients. PATIENTS with the pelvic congestion syndrome may lished by many investigators (Taylor, 1949; Allen present with varying symptoms including backache, and Masters, 1955; Alien, 1971). In the original vague feelings of pelvic discomfort, worse before papers on this condition radiological examinations and during the menstrual period, dysmenorrhoea, were not performed. Subsequently, methods to menorrhagia and dyspareunia. Some cases of investigate the pelvic veins were described. These recurrent 'cystitis', with negative bacteriological include, uterine phlebography (Guillem et al., 1951 ; examination and normal urography should be Kauppila et al., 1971; Chidekel and Edlundh, included in this syndrome. Peripheral venous 1968; Hughes and Curtis, 1962), renal phlebodisorders, vulval varicosities, thigh and leg varices, graphy and ovarian phlebography (Chidekel, 1968), swelling and discomfort in a limb may be the main trans-osseous phlebography (Guillem and Baux, presenting features. Thus patients may present to 1954), and cannulation of vulval varices (Lea the gynaecologist with predominant pelvic symp- Thomas et al., 1967). It is the purpose of this toms, to the general surgeon with leg varicosities paper to describe the investigation of 12 patients, and vulval veins or to the urologist with frequency all of whom had vulval varices. All the patients were considered to be suffering from manifestations and urgency of micturition. Dixon and Mitchell (1970) stated that varicose of the pelvic congestion syndrome. As these veins of the vulva are common, troublesome and patients were referred by a general surgeon, most ill understood. They found that 20 ~ of women also had symptoms and signs of peripheral venous developed varicosities during pregnancy and one disorders, but a few had trivial or no symptoms in three of these showed vulval involvement. Dodd referable to the legs. It is believed that radiological and Payling-Wright (1959) found that 8 % of women examination of these patients with vulval varicosibooked for antenatal care were referred to the ties is important. The peripheral leg varices may varicose vein clinic; 80 patients from a total of communicate with the vulval and pelvic veins 4267 booked for antenatal care had distressing and also the presence of pelvic varicosities may vulval varices, i.e. an incidence of 2 %. It is said explain the many pelvic symptoms about which that most of the vulval veins seen during pregnancy these patients complain. The pelvic veins were disappear following parturition. The patients in examined radiologically by percutaneous puncture this series had their last pregnancy many years of vulval varicosities. Table 1 lists the patients, their main symptoms, beforehand, with one exception when the time interval was one year. They were referred to a general clinical features and radiological findings. The surgeon with an interest in varicose veins. From a radiological appearances are seen in Figs. 1 to 7 series of 4000 patients with peripheral varicosities 40 were found to have vulval involvement, i.e. an TECHNIQUE OF EXAMINATION incidence of 1%. In all the cases reported in this series percuAn association between the pelvic congestion syndrome and pelvic varicosities has been estab- taneous puncture of a vulval vein was performed. 517
518
C L I N I C A L RADIOLOGY
It was not found necessary as in the series reported by Lea Thomas et al. (1967) to expose a vein for cannulation. A small butterfly needle (gauge 21) was inserted into a vulval vein and strapped in position. In some cases it was necessary to insert the needle with the patient standing, because the veins were not visible in the recumbent position. In these cases great care was necessary while moving the patient to a supine position, to avoid displacing the needle. Patency of the needle was maintained by gentle saline infusion. A small quantity of contrast medium was injected and observed on the television screen. I f satisfactory venous filling was obtained then 20-30 ml of Urografin 60 were injected and serial films were taken using a hand changer. Four or five 35 cm 2 films were usuMly sufficient. The direction of flow was observed on the television monitor and this direction was recorded by suitable timing of the film series. The patency of the needle was maintained by saline infusion until the films had been viewed. I f necessary a further injection was made and a second series taken. A 40 degrees oblique supine film was found t o be the most satisfactory for visualising the pelvic veins. This had been noted by Lea Thomas et al. in their series. It is important at the completion of the examination to infuse sufficient saline to clear the varices of contrast, to minimise the risk of phlebitis. When contrast lingers in the varices or if the needle becomes displaced, then vulval massage is advisable to encourage venous flow. The patients have all attended as out-patients, and no premedication has been found necessary in those patients examined so far. The examination can be completed within 15 minutes of a satisfactory venepuncture.
(d) Visualisation or otherwise of the internal iliac vein. It was clear that all the cases with peripheral leg varicosities demonstrated a communication with the saphenous or femoral veins via the superficial or deep external pudendal veins, and reflux of contrast down the leg was common in most of these. The cases with the more severe pelvic symptoms had the most marked pelvic varicosities. Varicosities in the vesical plexus were associated with the 'irritable bladder syndrome'. Those patients with dyspareunia had varicosities of the vesical plexus, pudendal vein or broad ligament varicosities. Only five of the 12 cases examined showed filling of the internal iliac vein. This could not however be taken, as definite evidence of occlusion of the internal iliac vein. The findings on vulval phlebography would indicate that there is some merit in the investigation of patients with vulval varices: The general surgeon treating peripheral leg veins should examine carefully for vulval involvement. O f ten cases examined by Dixon and Mitchell (1970) eight had communications with the saphenous system, and
DISCUSSION All the patients had vulval varicosities. The clinical features could be divided into three main groups. (a) Vulval varicosities, pelvic symptoms and peripheral leg varices, six cases (Table 2)_ (b) Vulval varices and peripheral leg symptoms only, two cases (Table 3). (c) Vulval varices and pelvic symptoms only, 4 cases (Table 4). In all, there were four main radiological findings : (a) Varicose pelvic veins. (b) Altered flow routes. (c) Communication with the peripheral leg veins.
FIG. 1 Case 1. - Pudendal vein filling (1). Utero-vaginal varices (2). Internal iliac vein (3).
VULVAL PtlLEBOGRAPHY
IN THE P E L V I C C O N G E S T I O N S Y N D R O M E
519
F~G. 2 Case 2. - Vulval varices (l). Obturator vein (2). Ascending lumbar vein (3). Presacral vein (4). N o internal iliae vein filling.
F~a. 3 Case 3. - Bilateral vulval varices (I). Obturator vein (2). Vesical plexus varices (3). N o internal iliac vein filling.
Fie. 4 Case 4. - Vulval varices (1). Internal pudendal vein varicose (2). External iliac vein (3), filling via superficial external pudendal vein. N o internal iliac vein filling,
F~G_ 5 Case 5. - Vulval varices (1)_ Pudendal vein varicosities (2). Obturator vein (3). Internal iliac vein (4).
520
CLINICAL
RADIOLOGY
FIG. 6 Case 7. - Enlargement o f vulval varices (1), with bilateral filling and contralateral flow to obturator vein (2).
, FIG. 7 Case 11. - Vulval veins (1). F e m o r a l vein (2). Varicose vesical veins (3). External iliac vein (4).
two had varices originating from the gluteal region. These authors also advocated direct vulval injections radiologically. Gyneacologists should also investigate patients with vulval veins and symptoms of the pelvic congestion syndrome. Many of these patients have vague symptoms of pelvic discomfort, menorrhagia and dysmenorrhea which are unexplained. Dyspareunia can be sufficiently severe as to lead to marital distress and psychiatric help may be sought. Recurrent bladder symptoms which present to the urologist and have negative excretion urography and negative bacteriological examinations are common. A search should be made for vulval veins which in these cases may be associated with vesical plexus varicosities. In patients with the pelvic congestion syndrome, apart from the presence of vulval varices, physical examination may be very disappointing. Allen and Masters (1955) described tenderness of the cervix which may be excessively mobile and which they termed the 'universal joint cervix'. This is not an impressive clinical sign. It is important that in looking for varices the patient should be examined standing. Quite marked vulval varices may not be visible when the patient is examined supine. Chidekel (1968) said that the precise cause for the occurrence of pelvic varicosities in women is not clear and Guillem et al. noted that very little attention has been paid to pelvic varicosities in gynaecological diagnosis. It has been suggested that pregnancy may produce pelvic venous compression and secondary incompetence of pelvic veins (Kaupilla et al., 1971; Chidekel and Edlundh, 1968), and certainly the pelvic congestion syndrome has been
described mostly in multiparous patients. There is often a history of pelvic complications relating to one pregnancy, following which these symptoms developed and in the patients in this series the occurrence of vulval varices could all be related to a particular pregnancy. Although entirely speculative it is suggested that thrombosis of the internal iliac vein or some of its tributaries might well produce this syndrome. There was filling of the internal iliac vein in five of these 12 patients and no thrombi were visualised. However the cases were all examined many years following the onset of symptoms. The pattern of the pelvic veins varied greatly from case to case, but the flow routes were altered and also varied in each case. It would be possible for thrombosed areas to exist in internal iliac vein tributaries and not be visualised. Murray and Comparato (1968) noted that in 31 patients examined by uterine phlebography, a filling defect was seen in the ovarian or uterine veins of one or both sides. These authors also thought that uterine phlebography was the only method short of surgical means that confirms a diagnosi s of the pelvic congestion syndrome. The methods for examining the pelvic veins include the trans-uterine route, the trans-osseous route and renal vein and ovarian catheterisation. By these routes not all the visceral veins are visualised and vulval varices may not be filled. Abnormal flow routes may not be seen, and communications with peripheral leg varicosities will not be outlined. Although cannulation of vulvavarices by surgical exposure has been described, it is suggested that percutaneous puncture of vulval varices is a more satisfactory, less time
V U L V A L P H L E B O G R A P H Y IN THE P E L V I C C O N G E S T I O N SYNDROME
521
TABLE 1
Pt.
Age
Presenting complaint
R.W. 1
42
Varicose veins both legs for 22 years, worse during periods. Vulval veins ruptured during second pregnancy_
N.W.
2
3_L.
3
30
Pregnancies
Clinicalexamination
Radiology
Varicose veins both legs. Large vein on left thigh controlled by compressing vulval veins.
1. Vulval filling. Contrast passed from vulval veins to saphenous vein and down leg. Also to pelvis via obturator and internal pudendal vein. Utero-vaginal varicosities, Interna/ iliac vein filling high in pelvis. 2. Ascending phlebography normal external iliac vein.
Varicose veins both legs. Aching vulval varices. History of heavy feeling in pelvis. Bilateral oophorectomy for small ovarian cysts, Abdominal discomfort persisted.
Large superficial varices thighs and lower legs. Vulval varices, worse on right side.
1. Vulval phlebogram. Vulval varices. Obturator vein filling. No internal iliac vein filling. Ascending lumbar and pre-sacral vein filled. Large varicose internal pudendal vein. 2. Ascending phlebogram - block of popliteal vein and lower femoral vein. External iliac vein patent.
Severe pains in vulval area for four years, worse before and during menses. Dyspareunia, pelvic discomfort.
Large vein extending from left labium major to perineum. Trivial veins both lower legs.
1. Vulval phlebogram. Filling of vulval varices, obturator and pudendal veins on contralateral side. Vesical plexus varices on both sides_ No internal iliac vein filling. 2. Ascending phlebogram. Normal external iliac vein.
2
522
CLINICAL RADIOLOGY
TABLE 1 (contd.)
Clinical examination
Radio logy
Varicose veins for 20 years. Recently worse before and during periods. Last two pregnancies complicated by thrombophlebitis_ Discomfort in pelvis and vulval varices.
Varicose veins both legs. Large vein on medial aspect of left thigh communicatifig with posterior part of labium major.
Vulval phlebogram_ Vulval varices on both sides. La ge internal pudendal vein filling vesical varices. Contrast passing via superficia external pudendal vein to external iliac vein and also dow the leg. No internal i filling.
Vulval veins. Feeling of pelvic pressure worse during periods. Legs ache during periods.
Trivial veins in both lower limbs. A group of veins on upper medial aspect of thigh, not related to sapheno-femoral junction.
Vulval phlebogram. Contrast )assed to thigh vessels and also via obturator vein to internal iliac vein high in the penis. Dilated internal pudendal vein and uterc ginal varices.
Vulval varices. Pelvic discomfort worse during and before periods. Dyspareunia severe. Recurrent 'cystitis' with negative urology.
Vulval varices. Trivial leg varices.
Vulval phlebogram. Varicose ,rnal pudendal vein and vulval varices. Filling of intern~ iliac vein. Communication with saphenous and femoral vein in thigh and contrast ~assing to external iliac system.
Pt.
Age
Presenting complaint
M.M. 4
37
S,P. 5
3l
J.K, 6
45
Pregnancies
V U L V A L P H L E B O G R A P H Y IN THE P E L V I C C O N G E S T I O N SYNDROME
523
TABLE 1 (contd.)
Clinical examination
Radiology
"Vulval heaviness most marked after coitus. Vulval varices 12 years. Since last pregnancy, thigh varices - legs ache during menses.
Large vulval varices. Superficial thigh varices communicating with vulval varices.
Yulval varices communicating with thigh varices. Obturator vein filling and upper part of internal iliae vein filled_ Some contrast passing to contralateral side. Contrast also passing to femoral vein in thigh.
32
Vulval varices since last pregnancy one year ago, but varicose veins in legs for eight years and legs ache particularly during menses.
Veins on medial sides of both thighs, which communicate with the vulval veins.
Vein high in left thigh injected, Vulval veins filled, but also contrast passed to femoral vein and retrogradely down the leg. Poor obturator filling, but vesical veins filling from the internal pudendal system. Bilateral pelvic filling from left side. No filling of internal iliac vein, external iliac vein normal.
38
Yulval varices since second pregnancy. Dyspareunia and fullness in vulva persisting until following day after coitus, 'irritable' bladder_ Peristent fullness in both legs.
Left vulval veins.
Left vulval vein injected. Contrast passed down leg to femoral vein and into normal external iliea vein. Filling of vulval varices, pelvic veins irregular and broad ligament varices filled.
Pt.
Age
Presenting complaint
M.P. 10
39
C.A. 11
M.A. 12
Pregnancws
CLINICAL RADIOLOGY
524
TABLE 1 (contd.) Pt.
Age
Presenting complaint
P,Y.
Clinical examination
Radiology
51
Varicose veins right leg 33 years, left leg ten years. Right leg heavy and painful especially before and during periods. Veins injected in right leg 1944 and 1958. Long saphenous on right stripped 1957. Vulval varices worse after second pregnancy in 1954.
Varicose veins both legs. Thigh veins on the right communicate with the posterior vulval veins.
Right vulval phlebogram. Contrast passed to femoral vein via deep external pudendal vein. Large vulval varices filled. Obturator vein filling and internal iliac vein filled. No vesical or para-uterine veins filled. Contralateral vulval veins and obturator veins filled.
M.L. 8
34
Varicose veins both legs 13 years. Pelvic pain and dyspareunia relieved by hysterectomy. Urgency of micturition persists.
Varicose veins both legs mainly inner aspects of thighs. Vulval varices most marked on the left side.
Left vulval phlebogram. Contrast passed to femoral vein. Vulval varices filled. Obturator filling but no internal iliac filling. Contrast passed to contralateral obturator vein. Varicose vesical plexus.
R,P,
45
Bilateral varicose veins 19 years, worse following groin ligations. Pelvic pain and 'cystitis'. Vulval varicosities after first pregnancy, subsequently getting worse.
Bilateral varicose veins. Long saphenous vein on both sides communicates with vulval varices.
Vulval varices injected. Contrast passed down leg to superficial varices and then to femoral vein. Filling of external iliac system. No filling of internal iliac vein.
7
9
Pregnancies
consuming procedure, which can be p e r f o r m e d as a purely radiological technique o n an out-patient basis. By this route, the vulval veins, the visceral pelvic veins, a b n o r m a l flow routes a n d peripheral leg varices can be seen. A l t h o u g h this radiological e x a m i n a t i o n has a p a r t to p l a y in explaining the patients' s y m p t o matology, it is also a d v o c a t e d as influencing the treatment. Pelvic a n d vulval c o m m u n i c a t i o n s should be dealt with surgically if they are seen to c o m m u n i c a t e with the p e r i p h e r a l leg veins. S a p h e n o - f e m o r a l ligation a n d / o r vein stripping will be insufficient for leg varices in these cases. D i x o n a n d Mitchell a d v o c a t e d four points of o p e r a t i o n in these patients, (1) internal p u d e n d a l vein, (2) o b t u r a t o r vein, (3) r o u n d ligament veins, (4) greater saphenous tributaries, i.e. superficial and deep external p u d e n d a l veins. A p p r o p r i a t e surgical exposures were described. In the pelvic congestion s y n d r o m e g o o d results have been recorded following h y s t e r e c t o m y and
this m a y be explained b y the reduction in pelvic b l o o d flow following arterial and venous ligation.
Acknowledgements. - We wish to thank Dr Cardew and the staff of the Audio-Visual Communication Department of St Mary's Hospital Medical School for the prints of the X-rays. We also wish to acknowledge the helpful criticism and advice given by Dr Ian Isherwood in the preparation of this paper.
REFERENCES ALLEN, W. M. & MASTERS, W. H. (1955). Traumatic laceration of uterine support. American Journal of Obstetrics and Gynaecology, 70, 500-513. ALLEN, W. M. (1971). Chronic pelvic congestion and pelvic pain. American Journal of Obstetrics and Gynaecology, 100 (2), 198-202. CHID~EL, N- & EI~LUNDH, K. O. (1968). Trans-uterine phlebography with particular reference to pelvic varicosities. Acta Radiologica (Diagnosis), 7, 1-ll.
525
VULVAL P H L E B O G R A P H Y IN THE PELVIC CONGESTION SYNDROME TABLE 2
TABLE 4
CASES WITH PELVIC CONGESTIONSYNDROME, VULVAL
CASES WITH VULVAL VARICES AND PELVIC SYMPTOMS
VARICES AND PERIPHERAL VARICOSITIES
Symptoms Symptoms
Radiology
l
Pelvic discomfort Leg varices
Internal pudendal veins Utero-vaginal varicosities Internal lilac filling Saphenous filling
2
Pelvic discomfort Leg varices
Varicose internal pudendal vein No internal iliac filling Block popliteal vein
4
Pelvic discomfort Leg varices
Varicose internal pudendal veins No internal iliac filling Superficial external pudendal vein to external lilac and leg veins
Pelvic discomfort Dyspareunia Urgency of micturition Leg varices
Varicose vesical plexus Obturator vein filling No internal ifiac filling Femoral vein filling
Pelvic discomfort Urgency of micturtion Leg varices
No filling of internal iliac vein Femoral vein filling
Vulval discomfort especially after coitus Leg varices
Obturator vein filling Internal iliac vein filling Femoral vein filling
10
TABLE 3 CASES WITH VULVAL VARICES AND LEG SYMPTOMS ONLY
Symptoms 7
34
Radiology
Bilateral varicose veins Vulval veins Worse during menses
Obturator vein filling Internal iliac vein filled Femoral vein filling
Leg varices ache during menses
Obturator vein filling Vesical varices Bilateral pelvic vein filling No internal iliac vein filled
12
Radiology
Vulval pain worse during menses Dyspareunia
Obturator vein. Contralateral Pudendal vein. Contralateral Vesical varices No internal iliac filling
Pelvic pressure worse during menses
Obturator vein Internal pudendal vein Utero-vaginal varices Filling of internal iliac vein
Pelvic discomfort worse during menses Dyspareunia Urgency of micturition
Internal pudendal varices Filling of intei:nal lilac vein
Vulval discomfort Dyspareunia Irritable bladder
Broad ligament varices Some contract to external iliac vein No internal iliac filling
CHIDEKEL, N. (1968). Renal phlebography in female pelvic varicosities. Acta Radiologica (Diagnosis), 7, 193-209, DODD, H. & PAX'LING-WRIGHT,H. (1959). Vulval varicose veins in pregnancy. British Medical Journal, 1, 831-832. GUILLEM, P., BAUX, R., VOlSlN, R. & PAILLE, J. (1951). La phlebographie pelvienne par vole uterine_ Gynaecologie et Obstetrique, Supplement Bulletin de l'Association des Gynaecologues et Obstetriques de Langue Franfaise, 4, 709-713. GUILLEM,P. & BAUX, R. (1954). La PhlebographiePelvienne. Masson et Cie, Paris. HUGHES, R. R. & CURTIS, D_ D. (1962). Uterine phlebography. American Journal of Obstetrics and Gynaecology, 83, 156-164. KAUPILLA, A., JARVINEN, P. A. & VUORINEN, P. (1971). Improve visualisation in uterine phlebography. British Journal of Radiology, 44, 284-289, LEA THOMAS, M., FLETCHER,'E. W. L., ANORESS, M. R- & COCKETT, F. B. (1967). The venous connections of vulval varices, ClinicalRadiology, 18, 313-317. MURRAY, E. & COMEARATO,M. (1968). Uterine phlebography, American Journal of Obstetrics and Gyneacology, 102, 1088-1093. TAYLOR, H. C. (1949). Vascular congestion and hyperemia. American Journal of Obstetrics and Gynaecology, .57 (2), 211-227, 637-653,654-668. DtxoN, J. A. & MITCHELL, W. A. (1970). Venographic and surgical observations in vulval varicose veins. Surgery, Gynaecology and Obstetrics, 131,458-464.