Anatomical, Pathophysiological, and Clinical Aspects of Extra-Pelvic Varicose Veins of Pelvic Origin

Abstract

Venous hypertension in the pelvic veins can result in the development of varicosities in the perineum, and sometimes also in the lower extremities. These varicose veins are anatomically and functionally different from typical varicosities associated with an incompetence of the saphenous veins. Since the pelvic cavity is anatomically separated from the lower extremity and perineum by muscles and skeleton, there are only a few routes through which pelvic veins can communicate with extra-pelvic veins. These routes should primarily be examined during diagnostic workout. In this review article, clinical anatomy concerning varicose veins of pelvic origin is presented, and the anatomically-driven diagnostics for these atypical varicose veins are discussed. Focus on ultrasonographic detection of the escape points, which are located at the sites where the incompetent intra-pelvic and extra-pelvic veins are connected-such as the perineal veins, veins running alongside the round ligament of the uterus, the obturator vein, as well as the inferior and superior gluteal veins-is emphasized.

Keywords: extra-pelvic varicose veins of pelvic origin; pelvic escape points; pelvic vein incompetence; pelvic venous disorders.

Figure 1

Female pelvis seen from above, with openings in the pelvic floor and veins providing communication with the perineum, gluteal area, and the lower limb. I—the inguinal canal through the veins of the round ligament of the uterus; O—the obturator foramen through the obturator veins; P—the lesser sciatic foramen through the internal pudendal veins; G—the greater sciatic foramen through the gluteal veins.

Figure 2

Transverse section of the female perineum with tributaries of the internal pudendal veins.

Figure 3

(a) Sagittal and (b) transverse sections of the male perineum with tributaries of the internal pudendal veins.

Figure 4

Ultrasonographic assessment of the clitoral pelvic escape point and related varicose veins (VVs): incompetent clitoral pelvic escape point (red arrow) on the (a) left and (f) right side of the clitoris (yellow arrow), resulting in (b,e) a dilated and incompetent external pudendal vein (green arrow) forming VV clusters at the mons pubis and the inguinal area, causing (c,d) atypical VVs (blue arrow) at the anterior aspect of the thigh.

Figure 5

Varicose veins in female patients caused by an incompetent clitoral escape point and reflux extending to the external pudendal veins: (a) atypical varicose veins at the anterior aspect of the thigh; (b) varicose veins related to the incompetent anterior accessory saphenous vein; (c) vulvar varicosities associated with incompetence of the anterior labial veins, tributaries of the external pudendal veins.

Figure 6

(a) Connections between pelvic veins (the deep dorsal vein of the penis, tributary of the internal pudendal veins) and superficial veins of the scrotum and lower extremity; (b) scrotal varicosities caused by incompetent internal pudendal veins, connected to incompetent external pudendal vein and anterior scrotal veins.

Figure 7

Ultrasonographic assessment of the intermediate labial escape point in females presenting with extra-pelvic VVs of pelvic origin; (a) longitudinal view of an enlarged vein of the vestibular bulb (arrow) extending along the anterior wall of the vagina; (b) transverse view of an enlarged vein of the vestibular bulb (arrows) located in the space anteriorly to the vagina.

Figure 8

Varicose veins related to the incompetent intermediate labial escape point; (a) atypical varicosities (arrow) at the medial aspect of the thigh; (b) varicosities (arrow) in the vulvar area.

Figure 9

Perineal escape point in a female patient; (a) duplex ultrasonography (longitudinal view) of an incompetent and dilated perineal vein (yellow arrows), running alongside the posterior wall of the vagina, between the vagina and rectum; (b) atypical varicose veins (green arrows) related to incompetent perineal veins.

Figure 10

Perineal escape point in a male patient; (a) duplex ultrasonography (longitudinal view) of the perineal veins (yellow arrows), revealing their tortuous course anteriorly from the rectum, where they join the internal pudendal veins; (b) varicose veins of the scrotum (red arrows) related to incompetent posterior scrotal veins, tributaries of the perineal veins.

Figure 11

The inguinal pelvic escape point: (a) duplex ultrasonography of incompetent round ligament vein (yellow arrow) in the inguinal canal, connected to the external pudendal vein (red arrow); (b) extra-pelvic varicose veins of pelvic origin (blue arrows) related to the inguinal pelvic escape point in female patient; (c) male patient.

Figure 12

Anatomical scheme (a) of the gluteal pelvic escape points related to the superior and inferior gluteal veins; (b) ultrasonographic view of the superior gluteal pelvic escape point (yellow arrow) located above the piriformis muscle; (c) extra-pelvic varicose veins of pelvic origin (blue arrow) associated with the superior and inferior gluteal escape points.

Figure 13

The obturator pelvic escape point; (a) anatomical scheme of the topography of the obturator vein; (b) ultrasonographic view of obturator pelvic escape point (yellow arrow); (c) extra-pelvic varicose veins of pelvic origin (red arrow) related to the obturator pelvic escape point.