Investigation & treatment of vaginal or vulval varicose veins
If varicose veins can be seen or felt in the vagina or vulva, then successful treatment will depend on proper investigations to find out the underlying cause and to direct the treatment.
In women who have symptoms of pelvic congestion syndrome ("dragging" feeling in the pelvis and/or irritable bowel and/or irritable bladder and/or deep dyspareunia - discomfort of sexual intercourse) the same tests are also needed even if there are no varicose veins seen or felt in the vagina or vulva.
There have been several tests suggested in the past, but only one is currently the "Gold Standard" test - Transvaginal colour duplex ultrasound.
Some of the tests are listed below:
Transvaginal colour duplex ultrasound - this is the gold standard test, as it shows the flow in the veins in the pelvis and doesn't need any needles or x-rays. However, it is only accurate when performed by very experienced duplex operators in units with a great deal of experience of this condition, as it is a complex test to interpret.
External colour duplex ultrasound (across the skin) - although it sounds much better to have an ‘external’ scan, rather than a transvaginal scan, the veins are too deep inside and at the wrong angle to get an accurate scan if the scanner is used across the skin of the lower abdomen.
MRI - Magnetic Resonance Imaging- this test can show large pelvic varicose veins and using a flow technique, can see some flow in the veins. However, it is expensive and some patients can feel claustrophobic in the MRI scanner. In addition, transvaginal duplex allows reverse flow to be seen when the pattern of breathing changes which is much harder (if not impossible) to see on the MRI scanner
Venogram (X-ray of veins with contrast injection) - a venogram is essential in the TREATMENT of pelvic or vaginal varices, but is not a good test at all to diagnose or investigate the condition. Firstly venography often misses reflux in the veins - the very thing one needs to see to diagnose the problem. In addition to that major problem, it uses X-rays (radiation) around the ovaries, involves injecting contrast and so is invasive and is more expensive than duplex ultrasound
CT (or CAT Scan - Computerised Axial Tomography) - CT has many of the same drawbacks as MRI - is better in that it doesn't have the problem of claustrophobia, but worse as it uses X-rays and so gives a radiation dose to the pelvis and ovaries
Treatment of vaginal or vulval varicose veins
Once the cause of the varicose veins has been found with a specialist transvaginal duplex ultrasound scan, our specialist surgeons can decide which of the internal and external veins need treatment.
Treatment of the internal pelvic veins - The veins in the pelvis that can cause pelvic congestion syndrome, vaginal and/or vulval varicose veins are the right and left ovarian veins and the right and left internal iliac veins.
All of these veins are best treated by ‘coil embolisation’. Using X-rays to guide the procedure, a very thin tube called a ‘catheter’ is passed from a vein in the neck into whichever of these veins needs to be treated. A special embolisation coil is then passed out of the catheter and into the vein - causing it to close around the coil instantly and blocking the vein permanently.
In the past this procedure used to be done from the vein in the groin. However, due to anatomy of the veins in the pelvis and abdomen, trying to do this from the groin leads to a high failure rate.
Treatment of the vaginal / vulval varicose veins - Once the internal veins have been treated, the external veins can be treated. This can usually be done by injecting foam sclerotherapy into the veins using a duplex ultrasound to guide the foam into exactly the right place.
Special compression needs to be worn for 14 days and nights to get the best results - and for large veins, more than one treatment might be necessary.
Expected results from treatment
Having treated hundreds of patients since the year 2000, we have found that 99% of people receive a cure of their pelvic vein problems after one treatment (embolisation) - the remaining 1% need a second (or, very rarely, a third) procedure to close the pelvic veins.
In our experience, the foam sclerotherapy following the pelvic embolisation has always resolved the vaginal or vulval veins - although more than one treatment might be needed, if the veins are large or widespread.