Case notes
During a prenatal visit, a small, right-sided vulvar varicosity was noted in a 34-year-old woman, gravida 3, para 2. This same varicosity had increased in size between her first and second pregnancies, reaching a maximum dimension of 6 cm during the second pregnancy. It regressed after each delivery. During the third pregnancy, the varicosity expanded to a maximum length of 12 cm ( Figures 1 and 2 ).
Upon examination, the varicosity was nontender and compressible with no vaginal or perineal involvement. The patient’s medical history was otherwise unremarkable. She had an uneventful vaginal delivery with no lacerations at 39 weeks.
Conclusions
Vulvar varicosities in pregnancy can be common. Patients classically present with symptoms of vulvovaginal swelling, pressure, and pain that are exacerbated by prolonged standing. The grapelike cluster of veins develops from a redundancy in the venous drainage of the vulva. Most vulvar venous drainage occurs through the pudendal vein and its branches; the long saphenous vein serves as an additional route. Typically, blood collects in the varicosity because the vessels draining the superficial external pudendal vein or the internal pudendal vein–the long saphenous arch and the internal iliac vein, respectively–are incompetent. Vulvar varicosities can also be supplied through redundancy in the vaginal, uterine, obturator, or ovarian veins.
Areas of reflux and reverse blood flow can be identified with a pelvic angiogram or selective venography. Vulvar varicosities can be managed with conservative, occlusive, or sclerotic approaches. In pregnancy, conservative tactics are often best, since varicosities usually resolve rapidly after delivery. These include elevation of the lower limbs, elastic bandages, and adjustable vulvar support devices. If symptoms persist beyond the 6-week postpartum period, more aggressive treatment should be considered. When evaluating nonpregnant patients, the decision to pursue active management is guided by the size and symptoms of the varicosity and by the presence of persistent pain or pain following exercise and standing.
Occlusion by ligation, the main surgical intervention, can be performed directly via the perineum with multiple, longitudinal, perineal incisions. To be effective, accurate identification of any communicating venous tributaries is necessary. Possible adverse events include dyspareunia and disfigurement. Sclerotherapy has also been successful. Ethanol is a potent sclerosing agent but can cause severe pain, tissue necrosis, and nerve damage. Sodium tetradecyl sulfate injection, polidocanol injection, and polyiodinated iodine (not approved in the United States) are among other substances used.
Four months after delivery, our patient’s varicosity had regressed ( Figure 3 ). She remains asymptomatic.
