Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 3790  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
E-CORRESPONDENCE
Year : 2014  |  Volume : 59  |  Issue : 2  |  Page : 210
Vulvovaginal varicosities: An uncommon sight in a dermatology clinic


Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Medical College, Navi Mumbai, Maharashtra, India

Date of Web Publication21-Feb-2014

Correspondence Address:
S Jindal
Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Medical College, Navi Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.127757

Rights and Permissions



How to cite this article:
Jindal S, Dedhia A, Tambe S, Jerajani H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic. Indian J Dermatol 2014;59:210

How to cite this URL:
Jindal S, Dedhia A, Tambe S, Jerajani H. Vulvovaginal varicosities: An uncommon sight in a dermatology clinic. Indian J Dermatol [serial online] 2014 [cited 2019 Nov 15];59:210. Available from: http://www.e-ijd.org/text.asp?2014/59/2/210/127757


Sir,

Vulvar varicosity is a distressing disorder occurring in 10% of pregnant women, generally during the latter half of a second pregnancy and usually regresses postpartum. It may produce pelvic discomfort, vulvar pressure, pruritus, a sensation of prolapse, and may extend into the vagina.

A 23-year-old woman in the 27 th week of her second pregnancy was referred to us with a complaint of increasing heaviness and swelling of the vulvar region of a two-week duration, with increase on standing and reduction in the lying down position. On examination, partially compressible, tortuous blue-colored swelling having a 'bag of worms feel' on palpation were seen on the left upper labia majora, minora, vagina, and inner upper thighs [Figure 1] and [Figure 2]. There was no history of surgery, rapid increase in size of abdomen out of proportion of gestational age, white leg in previous pregnancy, or use of oral contraceptive pills. Pelvic ultrasound followed by color Doppler examination confirmed the diagnosis of gravid uterus causing vulvovaginal varicosities. Color Doppler of bilateral lower limbs showed incompetence of both saphenofemoral junctions, without associated deep vein thrombosis. The patient was managed conservatively. She had a normal delivery with regression of the swelling within one month of delivery.
Figure 1: Partially compressible, tortuous swelling having a 'bag of worms feel' on palpation seen on left upper labia majora, minora, and vagina


Click here to view
Figure 2: Similar lesions on upper, inner upper thighs


Click here to view


Hormonal influences, prostaglandins A1, A2, E1, and E2, and scarcity of valves in the pelvic veins facilitating free and profuse crossover circulation lead to increased chances of vulvar varicosities in pregnancy, usually apparent after 26 weeks of gestation. Dodd et al. analyzing 343 (8%) antenatal women, presenting in the varicose vein clinic, found that 80 (23.3%) had involvement of the vulva, 46 (19.5%) of whom presented between 12-26 weeks of gestation, whereas 34 (32%) presented after 27 weeks. [1] The anastomotic nature of the venous network can result in downward extensions to the vagina and the medial aspect of the thigh, anteriorly to the groin and mons veneris, and posteriorly to the anal margin. Fortunately, complications such as thrombosis or bleeding are rare. [2] Spontaneous bleeding appears to be of academic interest, and in practice is not observed. Bleeding during childbirth is associated with vaginal tears or an episiotomy; internal bleeding results in the formation of a hematoma, primarily affecting the labia. Vulvar varices are not an indication for a cesarean section delivery. [2]

Doppler sonography with deep inspiration and expiration is the preferred method of investigation. During pregnancy, Doppler sonography is especially requested in the following situations: [2]

  1. Early-onset vulvar varices (first two months of a first pregnancy), to look for a malformation.
  2. Unilateral vulvar varices (malformation, left iliac thrombosis).
  3. Superficial thrombosis of a vulvar varicose vein, to look for deep vein thrombosis.


Invasive investigations include laparoscopy, phlebography, vulval varicography, and retrograde gonadal phlebography, [3] these being of use especially preoperatively to accurately delineate the varices. The differential diagnosis includes inguinal hernia or Bartholin's gland cysts. As the varicosities tend to regress postpartum, the management is essentially conservative in the form of leg elevation, left-sided sleeping, compression hose, exercise, and the avoidance of sustained periods of sitting or standing. Active treatment, in the form of sclerotherapy (with 1% sodium tetradecyl sulfate, polidocanol, aetoxisclerol, and polyiodinated iodine) [2],[4] is deemed appropriate in postpartum patients in cases of:

  1. Unsightly or very symptomatic varicosities, to the extent of immobilizing the patient with pain, particularly during the third trimester
  2. Superficial thrombophlebitis
  3. Symptoms persisting beyond six weeks of the postpartum period (this appears to be a sufficient length of time to allow for spontaneous resolution). [3]


Local excision can also be attempted. [5] Left untreated, vulvar varicosities can persist and sometimes get worse in subsequent pregnancies. [5] We report this case of vulvar varicosities for its rarity and the intravaginal extensions which have rarely been described in the literature, and its infrequent presentation to the dermatologist.



 
   References Top

1.Dodd H, Wright HP. Vulval varicose veins in pregnancy. Br Med J 1959;1:831-2.  Back to cited text no. 1
    
2.Van Cleef J-F. Treatment of vulvar and perineal varicose veins. Phlebolymphology 2011;18:38-43.  Back to cited text no. 2
    
3.Verma SB. Varicosities of vulva (vulvar varices): A seldom seen entity in dermatologic practice. Int J Dermatol 2012;51:123-4.  Back to cited text no. 3
    
4.Ninia JG, Goldberg TL. Treatment of vulvar varicosities by injection compression sclerotherapy and a pelvic supporter. Obstet Gynecol 1996;87:786-8.  Back to cited text no. 4
    
5.Dmitrieva J, Dillon E. Vulvar varicosities presenting as bilateral vulvar masses in pregnancy. Journal of Diagnostic Medical Sonography (JDMS) 2006;22:387-90.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,168 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed11517    
    Printed31    
    Emailed1    
    PDF Downloaded58    
    Comments [Add]    

Recommend this journal