Direct transvaginal ultrasound-guided sclerotherapy for pelvic venous disease

Abstract

Objective

To report feasibility, safety, and clinical outcomes of direct transvaginal ultrasound (TVUS)-guided foam sclerotherapy for isolated periuterine/pericervical varices or residual venous reservoirs after prior embolization.

Methods

Prospective single-center observational cohort including consecutive women (January 2023-October 2025) meeting predefined inclusion and exclusion criteria. Procedures were performed under general anesthesia using ultrasound-guided transvaginal venous puncture with fluoroscopic confirmation. Low-nitrogen 3% polidocanol foam was injected directly into the targeted periuterine and pericervical venous plexuses until complete filling of the treated reservoirs was achieved. Primary end points were technical success and changes in the Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ) score at 1 month and 1 year. Normality was evaluated with the Shapiro-Wilk test, repeated-measures analysis of variance with Mauchly's test for sphericity, and Tukey’s honestly significant difference for pairwise comparisons (α = 0.05). Institutional review board approval was obtained, and informed consent was required.

Results

Twenty-three patients (mean age, 40.5 years) underwent treatment; 74% had a history of prior gonadal vein embolization and presented with persistent symptoms at inclusion, whereas 26% had no prior embolization and presented with isolated periuterine or pericervical varices without axial reflux. Technical success was 100%. The mean procedural time was 36.0 ± 12.5 minutes, and the mean fluoroscopy time was approximately 1 minute. The mean sclerosant volume was 18.5 ± 5.3 mL. Radiation exposure remained low, with a mean dose-area product of 1.945 ± 0.347 Gy cm² and a mean absorbed dose of 72.0 ± 3.1 mGy. All patients were discharged the same day and resumed normal activities the following day. Minor vaginal bleeding occurred in 82% the day after treatment; no menstrual disturbances were reported. TVUS follow-up showed complete closure of the treated periuterine and pericervical venous plexuses, without evidence of recanalization in any patient at follow-up. The PVCSS improved from 12.91 at baseline to 7.87 (1 month) and 7.96 (1 year); the PVVQ score improved from 75.97 to 46.12 and 50.32, respectively. Overall improvement was significant (P < .001). Tukey’s honestly significant difference confirmed decreases from baseline to 1 month and 1 year for both scales (PVCSS, P < .001; PVVQ, P < .003); the 1-month vs 1-year differences were not significant (PVCSS, P = .987; PVVQ, P = .094).

Conclusions

Direct TVUS-guided 3% polidocanol foam sclerotherapy achieved high technical success, as well as significant and durable symptom improvement at 1 year in this small, highly selected cohort, with no major complications or recanalization. The technique offers a minimally invasive, targeted option for periuterine and pericervical venous reservoirs, particularly in cases not amenable to conventional endovascular access.

Article Highlights.

• •Type of Research: Single-center prospective observational cohort study
• •Key Findings: Twenty-three highly selected women with isolated periuterine or pericervical varices or persistent venous reservoirs after gonadal vein embolization without untreated axial reflux underwent direct transvaginal ultrasound-guided 3% polidocanol foam sclerotherapy. Technical success was achieved in all cases. The mean Pelvic Venous Clinical Severity Score improved from 12.9 to 7.9 and the mean Pelvic Varicose Vein Questionnaire score from 75.9 to 50.3 at the 1-year follow-up. No major complications were observed.
• •Take Home Message: In selected patients without active gonadal or iliac vein reflux, direct transvaginal ultrasound-guided foam sclerotherapy is a feasible and safe minimally invasive option for treating periuterine or pericervical venous reservoirs, with sustained short-term symptom improvements.

Pelvic venous insufficiency (PVI) represents an underdiagnosed cause of pelvic varicosities and chronic pelvic pain. In the context of atypical lower limb varicosities, particularly in the vulvar or inguinal regions, pelvic varicosities are detected in approximately 2.5% of cases during duplex ultrasound assessment.¹ Among women with chronic pelvic pain, PVI, defined by reflux in the ovarian or internal iliac veins, has been reported in 62% compared with 19% in asymptomatic controls.² Although the true prevalence of PVI in the general population remains uncertain due to heterogeneity in diagnostic criteria, it is estimated that ≤30% of cases of noncyclical pelvic pain may be attributable to venous disorders.³

Uterine varicosities represent a subgroup of pelvic varicosities that do not necessarily depend exclusively on reflux from the ovarian or internal iliac vein.⁴ These varicosities may persist or recur after standard embolization due to atypical drainage pathways, extensive collateral networks, or localized venous hypertension within the uterine plexus.^5,6 It has been reported that some uterine varicosities persist despite ovarian vein embolization and may be independent of gonadal vein insufficiency.⁷ Furthermore, although ovarian vein incompetence is a frequent cause of PVI, hemodynamic studies have demonstrated considerable variability in pelvic venous drainage, suggesting that independent uterine or periuterine reservoirs may also contribute to venous reflux and symptom persistence, with or without prior gonadal embolization.⁴ This hemodynamic heterogeneity explains why a proportion of pelvic varices are not associated with gonadal vein incompetence, rendering the traditional ovarian vein embolization approach insufficient or inappropriate.^8,9

There is therefore a distinct subgroup of patients with uterine or pericervical varicosities that either persist after conventional gonadal vein embolization or present as an isolated finding in the presence of competent gonadal and hypogastric veins. In these scenarios, standard transcatheter endovascular approaches are technically challenging or not feasible, offering a limited likelihood of success due to venous competence or access limitations.¹⁰ In this context, ultrasound-guided direct transvaginal puncture followed by polidocanol foam sclerotherapy offers a minimally invasive approach to treat these venous reservoirs. The primary objective of this prospective study was to evaluate the feasibility, technical success, and safety of direct transvaginal ultrasound (TVUS)-guided polidocanol foam sclerotherapy for the treatment of isolated periuterine or pericervical venous reservoirs, or residual varices after prior embolization. Secondary objectives were to assess the short- and mid-term clinical outcomes using validated symptom scales, including the Pelvic Venous Clinical Severity Score (PVCSS) and the Pelvic Varicose Vein Questionnaire (PVVQ), as well as to describe procedural characteristics and imaging follow-up findings.

Methods

This prospective observational cohort study was conducted with consecutive patient inclusion based on predefined criteria and prospective data collection according to a standardized study protocol. The study was approved by the institutional review board in accordance with current ethical guidelines, including the Declaration of Helsinki, and written informed consent was obtained from all patients. All clinical, procedural, and follow-up data were recorded prospectively in a dedicated database by the treating physicians.

Inclusion criteria

• 1Pericervical or paravaginal varicose veins of ≥6 mm in diameter¹¹ demonstrated by TVUS examination, either as a de novo finding in the absence of ovarian axial reflux, as confirmed by abdominal ultrasound and magnetic resonance angiography (Fig 1), or as persistent/recurrent varices after prior gonadal vein embolization.
• 2.Chronic pelvic pain of venous origin lasting >6 months.
• 3.Absence of nonvenous causes of pelvic pain on gynecological evaluation.

Fig 1.

Magnetic resonance angiography pelvic phlebography demonstrating competent left and right ovarian veins with a periuterine varicose plexus (open arrows).

Exclusion criteria

• 1.Age <18 years or inability to provide informed consent.
• 2.Pregnancy (positive pregnancy test) or active breastfeeding.
• 3.Known allergy to sclerosant.
• 4.Any iliac vein stenosis determined by pelvic duplex ultrasound examination, computed tomography scan, magnetic resonance imaging (MRI), and/or catheter venography.
• 5.Any significant renal vein stenosis with resultant renal hilar varices/collaterals and lumbar collaterals identified on pelvic duplex ultrasound, computed tomography scan, MRI, and/or diagnostic venography.
• 6.Allergy to iodinated or gadolinium-based contrast.
• 7.Severe renal impairment (on chronic dialysis or an estimated glomerular filtration rate of <30 mL/min).
• 8.Post-thrombotic inferior vena cava or iliac or ovarian vein changes.

According to the previous inclusion and exclusion criteria, the study planned a consecutive case sampling process over a maximum period of one calendar year, or until a minimum of 20 patients successfully enrolled, whichever occurred first.

The following parameters were recorded: procedural feasibility, technical success (defined as successful ultrasound-guided transvaginal percutaneous access with embolic agent injection), amount of embolic material used, procedure duration, fluoroscopy time, postoperative analgesic requirements, complications, and clinical evolution (according to the PVCSS and PVVQ), including TVUS follow-up both at 1 month and 1 year.

Technical success was defined as successful ultrasound-guided transvaginal puncture of the target periuterine or pericervical venous reservoir, followed by complete filling of the treated venous segments with polidocanol foam, confirmed by real-time transvaginal duplex ultrasound examination and fluoroscopic contrast injection. Adequate sclerosant distribution was defined by homogeneous opacification of the venous reservoir with the absence of immediate drainage into untreated axial pelvic veins. Technical failure was defined as an inability to access the target venous reservoir, incomplete filling of the venous plexus, or early washout of the sclerosant precluding effective treatment. Recanalization was defined as the presence of any Doppler-detectable venous patency or flow within treated venous segments on follow-up TVUS.

Demographic, intraoperative, and follow-up data were recorded in a dedicated database and analysed using STATA version 14.2 (StataCorp). The Shapiro-Wilk test was used to assess the normality of quantitative distributions, given its greater statistical power and reliability compared with alternative normality tests in small samples.¹² PVCSS and PVVQ scores were analyzed using repeated-measures analysis of variance, with results presented as means and standard deviations. Assumptions for repeated-measures analysis of variance were verified, including the assessment of sphericity using Mauchly's test to reduce the risk of type I error. When a significant overall time effect was identified, post hoc pairwise comparisons between time points were performed using Tukey's honestly significant difference test to control for multiple comparisons and to describe the temporal pattern of change. Statistical significance was set at a P value of <.05.

All procedures were performed by a multidisciplinary team, including an interventional radiologist and a vascular surgeon, as part of the standard practice for endovascular procedures in our institution, and conducted in a hybrid operating room (Artis Pheno; Siemens Healthcare). During this initial experience, a gynecologist assisted with TVUS to facilitate the identification of the target venous plexus. According to institutional protocol, all patients received a single dose of intravenous cefazolin (1 g) as antibiotic prophylaxis and a single dose of deflazacort (6 mg) before the procedure. In a lithotomy position, target vessels were identified and venous patency was confirmed using transvaginal duplex ultrasound examination (Fig 2). A 6F, 10-cm introducer sheath (Radiofocus Introducer II; Terumo Europe) adapted with elastic bands was used as an endocavity guidance system for a 20G, 15-cm Chiba needle (Cook Medical) (Fig 3). TVUS was used for the real-time identification of the target venous reservoir and guidance of the puncture, and fluoroscopic contrast injection was used to confirm correct needle positioning and to evaluate the distribution of the sclerosant within the venous plexus.

Fig 2.

Intraprocedural transvaginal pelvic ultrasound image demonstrating power Doppler ultrasound (left) and color Doppler ultrasound (right) imaging for the assessment of the patency of the periuterine varicose venous plexus.

Fig 3.

A 6F, 10-cm introducer sheath adapted with elastic bands was used as a puncture guide for a 20G, 15-cm Chiba needle. The configuration is shown before use (left) and mounted on the transvaginal ultrasound (TVUS) probe during the procedure (right).

Three percent polidocanol foam with a low nitrogen content was used as the embolic agent in all procedures (Fig 4). The appropriate distribution of the sclerosing agent was confirmed both under fluoroscopic guidance and TVUS control.

Fig 4.

Image showing contrast injection via a transvaginal approach, demonstrating the periuterine varicose plexus before microfoam injection (left) and 3% polidocanol foam with low nitrogen content in a glass syringe ready to inject (right).

Results

Between January 2023 and October 2025, 23 female patients (mean age, 40.5 years; range, 19.0-75.0 years) were enrolled in the study. There were 17 patients (74%) who had a history of prior ovarian vein embolization and presented with persistent symptoms at the time of inclusion. Among these patients, 2 had previously undergone embolization using coils alone (9%), whereas the remaining 15 (65%) had been treated with N-butyl cyanoacrylate (NBCA) alone. No patients in this cohort had combined embolization with coils and NBCA. The six remaining patients (26%) had no prior embolization and presented with isolated periuterine or pericervical varices without axial reflux. Presenting symptoms are categorized in the Table, as well as the baseline PVCSS and PVVQ scores.

Table.

Longitudinal changes in Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ) score at baseline, 1 month, and 1 year after treatment

Outcome	Time point	Mean ± SD	Comparison	Mean difference	95% CI	P value
PVCSS	Baseline	12.91 ± 2.04	Baseline vs 1 month	−5.04	−6.38 to −3.71	<.001
	1 Month	7.87 ± 1.69	Baseline vs 1 year	−4.96	−6.29 to −3.62	<.001
	1 Year	7.96 ± 1.92	1 month vs 1 year	−0.09	−1.42 to 1.25	.987
PVVQ	Baseline	75.97 ± 12.02	Baseline vs 1 month	−29.85	−35.13 to −25.12	<.0001
	1 Month	46.12 ± 10.31	Baseline vs 1 year	−25.65	−32.13 to −22.48	<.0001
	1 Year	50.32 ± 13.27	1 month vs 1 year	−1.75	−2.45 to 1.26	.0939

CI, Confidence interval; SD, standard deviation.

Data are presented as mean ± SD, with pairwise comparisons between time points.

All procedures were technically successful, with a mean procedural time of 36.0 ± 12.5 minutes and a mean fluoroscopy time of 1 minute. The mean volume of foam sclerosant administered was 18.5 ± 5.3 mL. Radiation exposure during the procedures was low, with a mean dose-area product of 1.945 ± 0.347 Gy cm² and a mean absorbed dose of 72.0 ± 3.1 mGy. All patients were discharged on the same day and resumed normal activities the following day. Nineteen patients (82%) reported minor vaginal bleeding on the day after treatment. No patients experienced any disturbance of their normal menstrual cycle.

Follow-up transvaginal duplex ultrasound examinations at 1 month and 1 year demonstrated complete obliteration of all treated venous segments, with no Doppler-detectable flow or evidence of recanalization in any patient. The evolution of the mean PVCSS and PVVQ scores are displayed in the Table. There was a significant overall improvement (P < .001), reflecting a marked decrease in both the PVCSS and PVVQ scores from baseline to 1 month and 1 year. Treatment resulted in a substantial and early decrease in pelvic venous symptom severity, which was maintained at 1 year. The mean PVCSS decreased from 12.91 ± 2.04 at baseline to 7.87 ± 1.69 at 1 month (P < .001) and 7.96 ± 1.92 at 1 year, with no meaningful change between follow-up intervals. Similarly, PVVQ scores improved from 75.97 ± 12.02 at baseline to 46.12 ± 10.31 at 1 month (P < .003) and 50.32 ± 13.27 at 1 year, suggesting a sustained midterm clinical benefit.

Discussion

Pelvic venous disorders represent a heterogeneous group of conditions characterized by complex venous drainage patterns and multiple potential pathways for reflux dissemination within the pelvis.^13,14 Current management is based on embolization of incompetent gonadal veins and, when indicated, internal iliac tributaries, using coils, plugs, or liquid agents, with reported clinical improvement rates ranging from 70% to 90%.^15,16 However, recurrent symptoms and persistent pelvic varicosities are not uncommon, particularly in patients with multifocal venous reflux or in those with varices arising from the uterine and parametrial plexuses, structures that may not be adequately treated using conventional endovascular approaches.⁵ In this context, our study explored the clinical role of a direct TVUS-guided technique, seeking to clarify why this access works, which venous anatomies benefit most, and how it integrates within current therapeutic algorithms. Accordingly, the present study should be interpreted as a feasibility and proof-of-concept evaluation of this direct transvaginal approach in a highly selected patient population.

Direct transvaginal puncture represents a novel and valuable strategy for patients with recurrent pelvic venous symptoms or with varices located in territories that are inaccessible through axial venous routes. Many periuterine or parametrial venous lakes originate from deep, trabeculated plexuses that are not connected to incompetent gonadal or hypogastric veins and, therefore, cannot be reached using conventional endovascular techniques.^4,7,8 In these anatomical settings, an endovascular approach can be technically challenging and frequently ineffective, as competent axial trunks limit navigation and superselective catheterization of isolated venous reservoirs. In contrast, the transvaginal route provides more direct access to these deep venous lakes, enabling precise targeting and a more even distribution of the sclerosant throughout the varicose network. This aspect is of particular relevance in patients with persistent symptoms after apparently successful ovarian vein embolization, as well as in those presenting with de novo periuterine varices despite normal function of the gonadal and internal iliac veins.

From a technical standpoint, ultrasound-guided transvaginal access was feasible and associated with short procedural times and minimal radiation. All procedures were technically successful, and no major complications were recorded, consistent with existing reports supporting the safety of direct-access sclerotherapy in vulvoperineal or pelvic reservoirs.17, 18, 19, 20 General anesthesia was selected in this initial experience to ensure patient comfort and procedural control, given the sensitive nature of the transvaginal access and the learning curve associated with this technique. In the early phase, multiple puncture attempts were occasionally required to accurately access the target venous reservoir, which could increase patient discomfort under local anesthesia. However, with increasing operator experience and improved technical precision, we believe that selected cases could be performed under conscious sedation, suggesting that the need for general anesthesia may not represent an intrinsic limitation of the technique, but rather a reflection of the early learning curve.

The absence of recanalization on follow-up imaging reinforces that adequate sclerosant distribution was achieved, supporting the reliability of the technique, although these imaging-based findings should be interpreted within the context of the study's sample size and the use of ultrasound-based end points. However, given the plexiform and tortuous nature of pelvic veins, as well as the inherent challenges of ultrasound-based assessment in this anatomical setting, the absence of detectable recanalization should be interpreted with caution and may reflect limitations in imaging sensitivity rather than a true absence of residual flow.

The absence of significant postprocedural discomfort, menstrual alterations, or pelvic thrombosis further highlights its favorable safety profile. These characteristics underline that this minimally invasive approach can be incorporated into routine practice for appropriately selected patients without requiring complex equipment beyond TVUS examination and a standard puncture system.

In our cohort, treatment was associated with a consistent improvement in validated pelvic venous symptom scores. Decreases in both the PVCSS and PVVQ scores were observed as early as 1 month after the procedure and were maintained at 1 year of follow-up. This sustained improvement reflects not only the effective sclerosis of the targeted periuterine venous reservoir, confirmed by the absence of recanalization on TVUS follow-up, but also the positive clinical impact on key symptoms such as orthostatic pelvic pain, dyspareunia, and menstrual exacerbation. The magnitude and durability of symptom relief observed in our series suggest a potential therapeutic benefit of direct transvaginal sclerotherapy in patients with complex pelvic venous anatomy, particularly in those for whom conventional endovascular approaches have failed or are not feasible. Although these findings show a clinically meaningful benefit, they should be interpreted as exploratory, given the limited sample size and the noncomparative observational design of the study.

This improvement aligns with the growing understanding that periuterine venous reservoirs may play a key role in symptom persistence. This provides a logical framework for interpreting the relevance of our findings in the context of current hemodynamic evidence that demonstrates that pelvic venous reflux is frequently multifocal and that the uterine and parametrial venous plexuses may behave as independent reservoirs, which are not necessarily decompressed by isolated embolization of the ovarian or internal iliac veins.^14,21 This physiological heterogeneity provides a plausible explanation for persistent symptoms or residual uterine varices following an apparently successful gonadal vein embolization and supports the rationale for directly targeting the uterine plexus when reflux or focal varices are identified at this level.

Due to the extensive collateral network of the uterine venous plexus, mechanical embolic agents such as coils or vascular plugs may result in incomplete occlusion and limited penetration of the uterine and periuterine circulation. To overcome these limitations, alternative techniques using liquid embolic agents or sclerosants, such as cyanoacrylates or polidocanol foam, have been developed, allowing more comprehensive distribution within the uterine and periuterine venous plexus.17, 18, 19^,22, 23, 24, 25, 26

Our choice of sclerosant was guided by the limitations of alternative liquid embolic agents. Although NBCA provides strong occlusive capacity, its rapid polymerization and associated inflammatory reaction frequently result in significant procedural discomfort in highly innervated pelvic territories, making it suboptimal for direct transvaginal treatment.^24,27,28 Ethylene-vinyl alcohol copolymer, although better tolerated, acts predominantly as a mechanical embolic material and lacks meaningful sclerosing activity, raising concerns about its effectiveness in low-flow, trabeculated venous plexuses such as the periuterine circulation.29, 30, 31

For these reasons, and based on available evidence, neither NBCA nor ethylene-vinyl alcohol copolymer offered the ideal combination of penetration, stability, safety, and patient comfort required for direct access treatment of the periuterine reservoirs in our study population. The effectiveness of low-nitrogen 3% polidocanol foam observed in our series reinforces its suitability for complex pelvic venous territories. Polidocanol exhibits advantageous physicochemical properties, including stable microbubble formation, homogeneous distribution within intricate venous networks, and prolonged endothelial contact, which promote effective venous ablation.³² These characteristics are particularly relevant in the uterine plexus, where the trabeculated architecture limits sclerosant propagation and often reduces the efficacy of solid embolic materials or more diluted solutions.^22,23 The safety profile of polidocanol in the pelvic venous system is well established, and our study confirms these findings. No cases of pelvic venous thrombosis, systemic embolization, tissue necrosis, or allergic reactions were observed. These results are consistent with previous publications reporting that the detergent-anesthetic properties of polidocanol minimize endothelial irritation and procedural discomfort compared with agents such as ethanol.³²

Based on our experience in lower-limb venous interventions, higher concentrations of polidocanol appear to be more effective in achieving durable occlusion in venous structures with deep intrapelvic drainage pathways. Lower concentrations are more susceptible to dilution before reaching the target venous reservoirs, particularly within the trabeculated periuterine plexus. To our knowledge, there are no specific guidelines regarding the optimal sclerosant concentration for the treatment of periuterine or pelvic varices, and the available evidence is limited. Nevertheless, our results suggest that 3% polidocanol foam provides a favorable balance between efficacy and safety in this anatomical territory. Treatment sequencing represents a critical aspect in the management of pelvic venous disease. Some authors have proposed that ultrasound-guided phlebectomy or sclerotherapy of pelvic leakage points may be used as a first-line intervention, even without prior embolization of the ovarian or internal iliac veins.³³ These studies demonstrate that local treatment can provide durable results in carefully selected patients. However, in our clinical practice, when periuterine or pelvic varices are associated with demonstrable axial venous reflux, we preferentially address the incompetent axial source first, in line with the current pathophysiological understanding of pelvic venous disease, which emphasizes the identification and treatment of the primary source of reflux.^6,7,13 Direct treatment of periuterine venous reservoirs is then considered in cases of persistent symptoms or residual varices after correction of the axial reflux, or in the absence of a treatable axial source.

Our clinical strategy aligns with this principle. In our cohort, periuterine sclerotherapy was never performed in the presence of untreated gonadal vein insufficiency. The six patients treated as de novo cases had not undergone prior embolization because preprocedural imaging (TVUS examination and MRI) showed no evidence of gonadal or internal iliac venous reflux, and their periuterine varices appeared to originate from isolated uterine or parametrial reservoirs rather than from an axial pelvic trunk. Conversely, in the re-embolization group, symptomatic recurrence was not attributed to residual or recanalized axial reflux, but to deep periuterine venous reservoirs that had not been accessible through the previously embolized gonadal or hypogastric pathways. In these cases, the transvaginal approach represented the most direct and effective access route to the persistent varicose plexus. The proportion of patients with prior embolization in this study reflects the selected nature of the cohort and should not be interpreted as a recurrence rate after gonadal vein embolization. Importantly, all patients underwent comprehensive imaging assessment before inclusion to exclude persistent or contralateral gonadal vein reflux; patients in whom symptoms were attributable to untreated or newly developed axial gonadal insufficiency were not included and were instead referred for standard endovascular embolization of the incompetent axis.

Regarding prior treatments, most patients had undergone embolization using NBCA, a liquid agent that allows distal penetration into the periuterine venous plexus, partially mimicking the effect of sclerotherapy. In contrast, in the small subgroup of patients previously treated with coils, direct treatment of periuterine reservoirs had not been performed during the initial procedure, which may have contributed to the persistent symptoms in these cases.

Similar to the selection criteria proposed by other authors,^34,35 direct transvaginal sclerotherapy was only performed when duplex ultrasound examination and prior imaging confirmed the absence of a dominant refluxing connection between the target varices and a major pelvic trunk. This structured, reflux-oriented approach likely contributed to the absence of early recurrence in our series and reinforces the importance of addressing axial venous insufficiency, when present, before addressing residual periuterine reservoirs.

This study has several limitations. First, the sample size is small, reflecting the low prevalence of patients with isolated periuterine or parametrial varices unassociated with axial reflux. The limited number of cases restricts the generalizability of the findings. Second, no comparison was performed between polidocanol and other sclerosants or embolic materials, precluding conclusions regarding the relative superiority of this agent. In addition, the PVCSS and PVVQ, although disease-specific instruments, have limited external validation and are not yet universally adopted standardized outcome measures in pelvic venous disorders. However, they currently represent the most widely available tools for structured clinical assessment in this field. Furthermore, outcome assessments were not performed by blinded evaluators, which may introduce observer bias. Finally, although the study was prospectively designed, the inclusion threshold of 20 patients, chosen to ensure a minimum dataset describing feasibility, safety, and early clinical outcomes, remains arbitrary and warrants validation in larger prospective series.

Despite these limitations, the findings of this study support the feasibility and safety of direct TVUS-guided sclerotherapy in a highly selected group of patients with pelvic venous disease characterized by isolated periuterine, pericervical, or parametrial varices, or by residual venous reservoirs after conventional embolization. The technique complements current endovascular treatments by addressing venous anatomies that cannot be reached through axial routes, reinforcing its potential role within a structured treatment algorithm for pelvic venous disorders.

Conclusions

Ultrasound-guided direct transvaginal access sclerotherapy with low-nitrogen 3% polidocanol foam is a potentially feasible, safe, and effective therapeutic option in selected patients with pelvic venous disease characterized by isolated periuterine or parametrial varices, or by persistent residual varices following conventional embolization. In our cohort, the technique achieved high technical success rates and meaningful symptomatic improvement without major complications, although further prospective studies are warranted to validate these findings and refine patient selection criteria.

Author Contributions

Conception and design: JH, AA, RC, JL

Analysis and interpretation: JH, JL

Data collection: JH, RC, MP, JL

Writing the article: JH, AA, JL

Critical revision of the article: JH, AA, RC, MP, JL

Final approval of the article: JH, AA, RC, MP, JL

Statistical analysis: JL

Obtained funding: Not applicable

JH and AA contributed equally to this article and share co-first authorship.

Overall responsibility: JH

Funding

None.

Disclosures

None.