Vulvovaginal varicosities: An uncommon sight in a dermatology clinic

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 [Figures 1 and 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

Figure 2.

Similar lesions on upper, inner upper thighs

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.