Vulvar varicosities are a variant of varicose veins of the pelvis, in which the vessels of the labia and perineum are affected. It is manifested by a characteristic deformation of the veins, which expand, overflow with blood, become convoluted, knotted. Less than half of the patients, along with a cosmetic defect, have swelling, heaviness, dull pain in the external genitals. The diagnosis is made on the basis of external and gynecological examination data, the results of ultrasonography and selective varicography. During treatment, drugs with venotonizing, angioprotective, antiplatelet, phlebosclerosing properties are prescribed or crossectomy is performed.
Vulvar varicosities are usually detected in the gestational period. It is more or less pronounced in about 18-22% of pregnant women, in 4-8% of cases, pathological signs persist after childbirth. Often the disease is combined with other manifestations of varicose veins — vascular lesions of the lower extremities and pelvic organs, as well as hemorrhoids. Although in most cases the prognosis of external varicose veins is favorable, if it is present, the likelihood of thromboembolism and bleeding during childbirth increases. With significant vascular deformity, the patient’s quality of life significantly worsens — emotional disorders, problems in family and sexual relations arise.
A prerequisite for the expansion of the veins of the vulva and perineum is the functional failure of the vascular wall and a violation of the natural flow of venous blood in the vessels of the pelvis. As a rule, the insufficiency of the tonic-elastic function of the veins is innate, and the clinical manifestations of the disease occur under the influence of provoking factors. The probability of developing vulvar varicosities increases significantly in the presence of varicose veins of the lower extremities and/or pelvic organs in the genus. The trigger factors for the manifestation of the disease are specific changes that occur during pregnancy:
- Hormonal restructuring. Pregnant women have increased levels of progesterone and relaxin — hormones that promote relaxation of the smooth muscles of the vascular wall. As a result, the valves cannot cope with the reverse blood flow, venous stagnation occurs.
- An increase in the volume of circulating blood. During pregnancy, the volume of fluid in the vascular bed increases by a third, and an increase in pressure increases the expansion of veins.
- Violation of the outflow of blood from the pelvis. The main vessels of the retroperitoneal space are squeezed by an enlarged uterus. This leads to stagnation of blood in the lower part of the body and provokes the expansion of veins.
Additional risk factors are overweight, sedentary lifestyle, sedentary work or, conversely, significant physical activity. In some women, dilation of the perineal vessels that occurred during pregnancy persists after childbirth. This is facilitated by anatomical features and diseases that prevent normal blood flow in the pelvic organs — retroflexia of the uterus, endometriosis, chronic inflammatory processes (salpingitis, oophoritis, adnexitis), benign and malignant malignant tumors of the uterus and ovaries (subserous and submucous fibroids, cysts, etc.). According to the observations of specialists in the field of obstetrics and gynecology, the disease is more often diagnosed in patients who have been taking hormonal contraceptives for a long time.
In patients with varicose veins of the vulvar region, due to the reduced content of some types of collagen fibers, insufficient strength of the connective tissue base of the vascular wall is noted. With a decrease in the tone of smooth muscles, an increase in the volume and pressure of blood, the veins stretch, and their lumen expands to such an extent that it is no longer blocked by the valve apparatus. Overflow of the vascular network of the pelvis provokes venous reflux. In this case, blood is thrown into the subcutaneous veins of the external genitals, which leads to their varicose veins.
Usually, the expansion of the vulvar veins occurs during pregnancy. In primiparous women, the initial symptoms of the disease appear by 18-24 weeks, in repeat births — by 12-18. In 60% of patients, the only clinical manifestation of varicose veins is vascular deformity in the vulvar region. The vessels expand, look excessively convoluted, overflowing, flabby, with sac-like nodular protrusions. Varicose veins can be both unilateral and bilateral. In 40% of cases, women complain of swelling and heaviness in the labia, perineum and vagina.
With decompensation of vulvar varicosities by the end of the day or against the background of significant loads, women are concerned about burning, pulling, dull or aching pains that can radiate into the legs. In some patients, pain manifests itself periodically, has an acute character, is provoked by stress, fatigue, hypothermia, exacerbation of chronic diseases. Much less often there are complaints of discomfort and soreness during and after sexual intercourse. In cases where signs of varicose veins persist after childbirth, as the disease progresses, chronic pelvic pain and discomfort in the lower abdomen are noted, the menstrual cycle is disrupted, urination becomes painful.
Vulvar varicosities can be complicated by acute varicothrombophlebitis, in which the veins thicken, become painful, and the body temperature rises to 37.4-38.0 ° C. With traumatic effects in childbirth or during sex, a rupture of varicose veins with prolonged massive bleeding is possible. Against the background of increased venous pressure in the affected vessels and thinning of their walls, it is quite difficult to stop such bleeding. A formidable complication of varicose veins is thrombosis, in case of separation of a thrombus, pulmonary embolism is possible. In the chronic course of the disease with damage to the vessels of the pelvis, infertility develops in some patients.
The detection of specifically altered veins in a pregnant woman makes it possible to suspect the development of vulvar varicosities with a high degree of probability. At the diagnostic stage, it is important to confirm or exclude the diagnosis, determine the extent of the pathological process and identify possible causes of veno-venous discharge. The standard survey plan includes:
- Examination on the chair. In the area of the vulvar ring and in the vagina, dilated, convoluted, soft, nodular vessels are revealed. The walls of the vagina may look cyanotic, the smoothness of the arches is determined by palpation.
- Selective varicography. During contrast contrast phlebography, it is possible to determine exactly where venous blood is discharged into the veins of the vulvar region.
Since usually varicose veins of the perineum and vulva are combined with pelvic fullness, the patient is prescribed diagnostic procedures to assess the condition of the pelvic venous system. The most informative:
- Ultrasound angioscanning. Ultrasonography allows you to detect anechoic convoluted formations that usually pass along the rib of the uterus. The main veins are dilated, their contours are indistinct. The main venous collectors are enlarged in diameter.
- Doppler ultrasound of blood vessels. With vulvar varicosities, the peak systolic velocity in the internal iliac, ovarian and uterine veins is reduced.
- Laparoscopy. With a widespread varicose process in the pelvic cavity, thin-walled cyanotic formations with a stressed wall are visually revealed.
- CT of pelvic organs. During computed tomography with an amplified signal, convoluted dilated vessels with uneven areas become clearly visible.
In the classic course with characteristic external manifestations, the diagnosis of the disease does not cause difficulties. Since varicose veins are often accompanied by disorders of the blood coagulation system, an assessment of hemostasis is recommended (determination of APTT, thrombin time, fibrinogen level, etc.). In addition to the gynecologist, a phlebologist is involved in the management of the patient.
Therapeutic tactics are determined by the severity of clinical manifestations and the presence of complications, differs in patients during pregnancy and during childbirth. Pregnant women with uncomplicated vulvar and perineal varicose veins are prescribed the following groups of medications:
- Venotonic drugs. They enhance the contractile activity of the smooth muscles of the venous wall, compensate for valvular insufficiency.
- Angioprotectors. Protect the stretched vascular wall from damage, prevent aggregation of blood components on it.
- Antiplatelet agents. It is indicated to reduce the risk of thrombotic and thromboembolic complications.
Patients are recommended to wear tights with a high degree of compression, exclude products that cause constipation, limit physical activity, perform a special complex of physical therapy. If conservative treatment is ineffective and symptoms increase, it is possible to introduce phlebosclerosing drugs, in the most difficult cases, with confirmed reflux, a crossectomy is performed.
Since coagulation worsens with varicose veins, it is recommended to create a stock of donor blood at the stage of prenatal preparation. To prevent the rupture of varicose deformed vessels in childbirth, the affected soft tissues are gently squeezed by hand through a sterile diaper, perineotomy is performed. When varicose nodes rupture and bleeding occurs, the ends of the ruptured vessels are ligated, the conglomerate of nodes is repeatedly stitched. Patients with severe varicose veins are recommended to be delivered by caesarean section. If signs of the disease persist after childbirth, depending on the characteristics of the course, both conservative and surgical treatment can be prescribed.
Prognosis and prevention
In 92-96% of cases, signs of external varicose veins of the vulvar ring disappear independently after childbirth. The appointment of complex medical treatment to pregnant patients allows to reduce the severity of clinical symptoms and reduce the likelihood of a complicated course of labor. The efficiency of sclerobliteration and surgical removal of varicose veins reaches 90-95%. For preventive purposes, especially with hereditary burden, timely registration with an obstetrician-gynecologist, restriction of physical activity, normalization of rest, correction of diet with an increase in the number of products containing coarse fiber is recommended.