In the past two decades, there has been a shift in varicose vein management from conventional surgical treatments to outpatient interventional procedures. Depending on the type and site of the affected vein, patients now have many other treatment options—namely with ablation, glue, coil embolization and sclerotherapy. These minimally invasive options offer better disease control with maximal safety, less pain and less recurrence.
With increasing patient awareness, one of the common clinical scenarios interventionalists encounter now is female patients with pelvic varicosities associated with the presence of vulvar, perineal, inguinal, or gluteal varicose veins, sometimes also associated with lower-extremity varicosities.
The prevalence of vulvoperineal varices in the general population is still unknown. Yet, in a series of over 4,000 female vein clinic patients, as written about by J T Hobbs et al in a 1990 British Journal of Hospital Medicine paper, the incidence of vulvar varices was about 4%, rising to 40% in patients with pelvic venous insufficiency. These latter patients are typically multiparous women between 20 and 40 years of age suffering from coital aches, genital heaviness, discomfort, continuous arousal, as well as lower urinary symptoms in severe cases.
Despite it being a common problem, there are few publications discussing vulvoperineal varices management. Most of the treatment approaches are derived from case reports or very small case series. Management options include compression, ovarian and internal iliac veins embolization, surgical ligation or phlebectomy and ultrasound-guided sclerotherapy. The latter is becoming both the doctor and patient’s favourite treatment where suitable—being safe and almost painless. It involves injecting a sclerosing agent like polidocanol foam, which causes a biochemical reaction in the diseased vein that, in turn, causes the vein to collapse and harden, before it is then absorbed by the body. The use of vulvoperineal sclerotherapy has little evidence and is done under ultrasound guidance alone, which despite being sufficient for symptom improvement in most cases, does not allow full assessment of the veins going up to the pelvis.
This was our motive when developing direct fluoroscopic-guided sclerotherapy for vulvoperineal varices, which combines ultrasound guidance for vein puncture followed by contrast injection under real-time fluoroscopic guidance to assess all external genitalia veins and how they interact with pelvic and lower-limb veins.
We published the results on our first 70 patients in the Arab Journal of Interventional Radiology (AJIR) in 2021 and we have now treated more than 160 patients using this procedure.
Varices most commonly drain into the internal iliac veins through perineal and internal pudendal veins, and connections with the vaginal and external iliac veins were also noted. Ovarian venous connections were not as common as most of these patients had already undergone ovarian vein embolization prior to vulvar sclerotherapy.
Technical success was achieved in all cases, with all patients showing short-term improvement in their symptoms, whether from one or two sessions of sclerotherapy. For patients who completed a one-year follow-up, recurrence was found in only 7%. The rest of the patients showed a stable therapeutic effect with no recurring varices, pain, or labial swelling.
This new procedure will be discussed at the Pan Arab Interventional Radiology Society (PAIRS) annual congress that will take place in Dubai, UAE from 11–14 February. The congress provides the opportunity for all those interested in interventional radiology (IR) to network and improve their practice by attending sessions and workshops covering all categories of IR, including like interventional oncology, venous, embolization, aortic, women’s health and musculoskeletal, as well as a dedicated track for juniors with more than 150 speakers from all over the world.
Karim Abd El Tawab is a consultant interventional radiologist at Ain Shams University Hospitals, Cairo, Egypt.
Disclosures: Abd El Tawab is a member of PAIRS 2023’s Scientific Committee.