Varicose veins of the pelvis in men – stagnant fullness of the pelvic region, due to a change in the architectonics of the vessels. The main manifestation is intermittent aching dull pains in the lower abdomen, which increase with physical exertion. Some men note symptoms of dysuria: frequent urination, discomfort. Diagnostics includes transrectal ultrasound, Dopplerography, MRI (CT) of the pelvic organs. Treatment correlates with the degree of vascular damage and can be conservative (phlebotonics, anticoagulants, NSAIDs) with behavior correction or operative, aimed at eliminating varicose deformed vessels or the cause that led to the pathology.
I86.2 Varicose veins of the pelvis
Varicose veins of the pelvis (VVPM) in men, it disguises itself as a number of diseases: prostatitis, recurrent varicocele, hemorrhoids. Often these pathologies are present in various combinations. In addition to these diseases, in 57%, varicose veins of the pelvis are combined with dropsy of the testicle, spermatocele, hydatid Morgagni. The venous plexus of the prostate was first described at the beginning of the XVIII century by anatomist G.D. Santorini. Blood flows into it from the prostate, the bottom of the bladder, vesicles with further entry into the internal iliac vein. About 15-20% of men face VVPM, with age the probability of varicose veins of the pelvis increases.
Pathology can be congenital and acquired. In the first case, a genetic predisposition causes an innate weakness of the intima of the vascular walls. The deformation of the veins is also facilitated by the inadequate operation of the valve apparatus, which cannot withstand the additional load and creates a reverse blood flow. There are a number of conditions that lead to pelvic varicose veins:
- Vascular pathology. The syndrome of increased pressure in the portal vein system, arteriovenous conflicts, congenital vascular malformations increase the load on the veins, disrupting adequate blood flow to the heart and causing fullness of the pelvic organs. May-Turner syndrome, in which there is mechanical compression of the left common iliac vein by the right common iliac artery and the formation of internal spurs, is manifested by varicose veins and bilateral varicocele.
- Connective tissue dysplasia. Blood moves through veins and arteries under pressure. Improper development of connective tissue, which is lined with the intima of the vessel, leads to a violation of the structure of the vascular wall, its expansion (loss of elasticity) and even rupture. Part of the blood flows back from the heart, causing venous stagnation, and later – varicose veins and chronic venous insufficiency.
- The tumor process. A neoplasm of considerable size can squeeze the inferior vena cava and iliac veins, which also disrupts the blood flow. Below the obstacle, the vessels deform, there is a tendency to thrombosis. Similar consequences may occur with Ormond’s disease (retroperitoneal fibrosis). Chronic aseptic inflammation of connective and adipose tissue leads to compression of blood vessels and their change.
- Behavioral habits. Lack of physical activity, overeating contribute to the development of metabolic syndrome with disruption of the cardiovascular system. Chronic deposition of blood in the pelvis causes congestion. Venous stagnation is provoked by an unnatural delay in ejaculation, excessive masturbation, lack of regular ejaculation. Lifting weights is accompanied by an increase in pressure in the vessels and their gradual deformation.
An increase in venous pressure leads to a weakening of the vascular walls and varicose transformation. The valves cannot withstand the load, and part of the blood remains in the veins of the pelvis, which gives rise to a congestionof the genitourinary venous plexus, leads to venous hyperemia, disrupts microcirculation. The resulting chronic tissue hypoxia predisposes to inflammatory processes. Initially, there are functional changes – dilation of the veins of the genitourinary plexus, a decrease in the speed of blood flow, deposition and shutdown of a significant volume of blood from the circulation. The long-existing condition is complicated by the development of dystrophic and sclerotic processes in the intima of the veins, which aggravates congestion and metabolic disorders. Against this background, SHTB appears with a violation of urodynamics.
Clinical manifestations of pathology correlate with the degree of severity of vascular changes. If they are insignificant, there are no symptoms. In the advanced stages of the disease, pains of varying intensity appear in the lower abdomen, in the perineum, more often moderate, aching. Pain increases after lifting weights and walking, during sexual intercourse, after ejaculation. When defecation is associated with the need for straining with constipation, a third of patients report pain in the lower abdomen.
Typically, an increase in unpleasant symptoms with a change in the position of the body in space. Often the pain radiates to the lumbar region or hip. On examination, the perineum and scrotum are somewhat swollen. The more pronounced the congestion, the greater the likelihood of dysuric disorders joining. Frequent urination in small portions, a feeling of an overflowing bladder are typical manifestations of pelvic varicose veins.
Complications of varicose veins of the pelvis in men include infertility ‒ its probability is higher with concomitant bilateral expansion of the veins of the cluster-like plexus of the spermatic cords. Increased blood flow to the testicles causes disorders of spermatogenesis. Changes in the spermogram of varying severity are present in 25% of men with this pathology. Vascular deformity can lead to increased thrombosis, migration of a thrombus with thromboembolism, rupture of a vein with massive bleeding. Fibrosis, calcification and diffuse changes in the prostate by the type of chronic inflammation are noted in 45% of men. Varicose veins of the pelvis leads to erectile dysfunction, which is diagnosed in 83% of patients with varicocele. This is caused by pathological venous discharge and the formation of shunts between the spongy and cavernous bodies of the penis, sclerotic tissue changes, malformations of the vessels of the cavernous basin.
In men, 2-sided varicocele is always suspicious of concomitant pelvic varicose veins, especially if the pathology is recurrent. Pelvic phlebography with contrast injection can be performed if collateral branches from the iliac veins are suspected. Computer or magnetic tomography is also resorted to in cases where primary imaging tests could not fully clarify the situation. Patients need to consult an andrologist, phlebologist. The algorithm of research in this pathology:
- Visualization methods. Varicose veins of the pelvis and the veins of the spermatic cord are confirmed by transrectal ultrasound, Doppler mapping (ultrasound of the prostate) is used to assess the blood flow rate and the diameter of the vessels. Visualization of veins in the area of the dorsal venous complex is a criterion for confirming pelvic varicose veins in men. Ultrasound of the pelvic veins is a more accurate method that allows you to obtain a two-dimensional image of the vascular system. If erectile dysfunction of vascular genesis is suspected against the background of pelvic varicose veins, pharmacocavernosography is performed.
- Laboratory diagnostics. There are no specific tests to confirm varicose veins of the pelvis. The patient is prescribed a coagulogram to assess the blood coagulation system. The analysis of the native ejaculate (spermogram) shows violations of the process of spermatogenesis. Since the complaints are similar to clinical manifestations in prostate inflammation, its secret is examined using microscopy, with an increased number of leukocytes and bacteria, PCR diagnostics for venous diseases is performed. According to research, concomitant pelvic varicose inflammation in the prostate is detected in 72% of men.
Differential diagnosis is performed with non-vascular causes of chronic pelvic pain syndrome, prostatitis, tumor in the projection of the pelvis, retroperitoneal fibrosis. Any of these diagnoses does not exclude a combination with pelvic varicose veins, so if there is no effect from the therapy, or frequent relapses occur, a complete clinical and phlebological study is justified.
If vascular changes are insignificant, a man with varicose veins is recommended to eliminate the provoking factors, it is possible to conduct preventive course therapy with dynamic observation. In severe cases, the decision on the management of the patient is made collectively, taking into account the recommendations of the vascular surgeon, the patient’s age and concomitant pathology.
- Surgical treatment. When choosing an intervention, it is taken into account which veins have undergone varicose transformation, the cause of pathology. Indications for endovascular surgery: pronounced symptoms, bilateral varicocele (recurrent), confirmed varicose transformation of the prostate veins, compression of the iliac veins or the presence of their collaterals. With VVPM, angioplasty and stenting of the iliac veins can be performed, stent implantation to eliminate angiovascular compression, embolization of affected blood vessels, etc.
- Conservative therapy. In elderly patients without clinical manifestations, the management tactics are conservative: phlebotonics (synthetic and plant-based), anticoagulants, vitamins. Young people planning fatherhood, with concomitant 2-sided varicocele and pelvic varicose veins, need surgery. The effect of drugs is aimed at strengthening the vascular wall, reducing hemodynamic disorders. With pain syndrome, it is possible to use nonsteroidal anti-inflammatory drugs in short courses.
Prognosis and prevention
The prognosis for life at the initial stage of varicose veins is favorable. Varicose veins of the pelvic veins, with proper behavior, can last for a long time in a compensated form. The outcome for advanced stages of the disease depends on the timeliness of surgical intervention and correction of behavioral habits.
Preventive measures include adherence to a healthy lifestyle (regular exercise, proper nutrition), weight normalization, rejection of excessive physical exertion and, especially, weight lifting. Sexual behavior also largely determines the risk of developing varicose veins of the pelvis: interrupted or unnaturally prolonged sexual intercourse, masturbation without ejaculation and other sexual excesses are unacceptable, as they contribute to the creation of venous congestion in the pelvis.