Vulvar and perineal varicose veins

Vulvar and perineal varicose veins are diseased, dilated veins in and around the vulva and the perineum. They are caused by pelvic vein insufficiency and may, but not necessarily, result from pregnancy.

Vulvar varicosities can form during the second part of a pregnancy, after the fifth month. They usually disappear after the delivery, but can persist in some patients.

On examination, varicose veins in the vulvar and perineal region are usually visible to the naked eye. They may extend toward the gluteal fold, or deeper into the pelvis or anal area (in which case the patient may also experience symptoms of hemorrhoids).   

The physical appearance of these varicosities can change over time. In some cases, they only appear during the menstrual cycle or after intercourse. If located deep inside the body, they may even remain invisible.

Symptoms typically include pain or discomfort in the affected area, often accompanied by itching and swelling. Sometimes the pain or discomfort gets worse following intercourse. This is known as dyspareunia.

Pregnancy is the main risk factor. The presence of the fetus puts pressure on the pelvic area. This causes compression of the veins, which can no longer efficiently carry blood back to the heart. The blood starts to pool in the vulvar and perineal veins, which become dilated, causing symptoms to appear. In general, the excess pressure is alleviated during the delivery, and blood circulation returns to normal. However, in some patients, particularly after several pregnancies, the veins become damaged. They stay dilated and symptoms persist. 

Unlike pelvic varicose veins, which are deeper and not visible, vulvar and perineal varicose veins are typically visible to the naked eye, which makes them easier to diagnose.

A Doppler ultrasound is usually performed in addition to a clinical exam. It is used to produce a mapping of the affected veins and to check for the presence of pelvic varices around the uterus and ovaries. The practitioner can also identify any issues affecting the veins in the legs. In some situations, he or she might also order an MRI or CT scan.

Initial treatment involves lifestyle and diet-related measures:

• Wear compression stockings or socks to improve circulation, particularly during pregnancy
• Avoid crossing the legs when sitting
• Avoid overly hot baths
• Avoid clothing that is too tight in the groin area
• Facilitate venous drainage through massage, physical activity such as swimming or hiking, or cold water jets
• In the event of a painful flare-up, ice packs can provide some relief

Where there is significant damage to the veins, these measures become insufficient and an endovascular embolization procedure may be necessary.

Embolization is the first-line treatment for symptomatic pelvic varices and perineal varicose veins that resist appropriately administered medical treatment. Embolization consists in blocking the veins that no longer function properly around the perineum and vulva. As these varicosities are often associated with pelvic varices, the diseased veins in both the pelvis and perineal region are obstructed over the course of one or several procedures. In general, the veins are blocked using a bioadhesive combined with a sclerosant foam. Sometimes tiny platinum coils are inserted to block the larger vessels.

When the diagnostic assessment is accurate and all of the damaged veins are treated during the embolization, excellent outcomes are achieved. This type of treatment must be performed in a specialized center. The American Hospital is equipped with comprehensive diagnostic and testing infrastructure, which includes an operating room and MRI and Doppler machines. Our vascular physicians, radiologists and gynecologists have extensive experience in treating this complex disease, which often causes significant pain and is difficult to diagnose. But when accurately diagnosed, effective treatments are available.