Clinical Presentation and Evaluation of Pelvic Venous Disorders in Women.

The term pelvic venous disorders (PeVD) describes a group of related clinical entities with overlapping clinical presentations that were previously characterized by separate imprecise syndromic terminology. The clinical manifestations of PeVD may variously include chronic pelvic pain; pelvic origin extrapelvic lower extremity and genital varices; lower extremity pain and swelling; and left flank pain and hematuria. This manuscript focuses on the primary manifestations of PeVD in women - chronic pelvic pain and pelvic origin lower extremity and vulvar varices - and will review the underlying pathophysiology and related complicating factors (such as maladaptive pain responses) to explain the variety of clinical presentations.

Female Genital Hair-Thread Tourniquet Syndrome: A Case Report and Literature Systematic Review.

"Hair-thread tourniquet syndrome" (HTTS) describes the condition in which fibers of hair or thread wrap around an appendage (ie, toes, fingers, genital structures, tongue, uvula, and neck), eventually causing ischemia and tissue necrosis. To date, few cases of female genitalia HTTS have been described. We report a case of female genitalia HTTS in a 5-year-old girl and report the state of the art by systematically reviewing all existing evidence about female genital HTTS. A total of 29 studies, describing a total of 34 patients, were identified. The presence of a hair-thread wrapping genitalia should be suspected in prepubertal girls complaining of genital pain associated with vulvar/vaginal swelling, wide-based gait, and voiding symptoms. Genital examination disclosing an extremely tender, swollen, and erythematous lesion on the clitoris or labia minora encircled by a hair confirms the diagnosis. The aim of the management is to remove the hair-thread in the shortest time possible, with the use of forceps, scissors, or scalpels, and this is often performed under sedation/anesthesia because of the patient's pain reaction. When the hair-thread is difficult to find or when the lesion is necrotic, excision of the lesion itself can be the only option. Complications include partial or total amputation because of tissue necrosis and recurrence.

Surgical treatment of vulvar venous malformations without preoperative sclerotherapy: Outcomes of 18 patients.

BACKGROUND: Our aim was to evaluate the benefit of surgical resection of the venous malformations (VMs) of the external female genitalia. METHODS: Over the period of 2009-2019, 18 consecutive females underwent surgical resection for vulvar VM. Evaluations included preoperative Doppler ultrasound, MRI, and pre-and postoperative photographic imaging. The main outcomes were: residual pain, cosmetic distortion, residual VM, and quality of life. RESULTS: Over a 10 year periods, 18 females, mean age 35 years (range 9-71) were included in this study. All patients were symptomatic: 16 had intermittent pain or discomfort, 1 had bleeding and 2 requested cosmetic treatment. Of these cases, there were 5 isolated vulvar VM, 12 associated VM: 3 of the clitoral hood, 3 troncular pelvic vein insufficiency and 12 of the lower limb. Eight patients had undergone previous procedures: 2 sclerotherapy treatments (1-3 sessions), 4 partial surgical resections. There were 18 single resections in the vulva (7 focal, 11 complete), 2 partial resections in clitoral hood and 2 had resection of a VM in the perirtoneovaginal canal at the same time. The mean follow-up was 42. 9 months (range 6-120). Two patients were lost to followup at 6 months. For all patients, elimination of pain and soft tissue redundancy was achieved. Two patients had persistent discomfort and 2 requested cosmetic treatment. CONCLUSION: Surgical resection of vulvar VM can be the best approach with few postoperative complications, good functional and cosmetic results. Appropriate preoperative evaluation is required to identify isolated VM or VM associated with ovarian vein or internal iliac vein insufficiency requiring to be treated before surgery.

Safety and effectiveness of percutaneous sclerotherapy for venous disorders of the labia majora in patients with vascular malformations.

OBJECTIVE: The aim of this study was to evaluate the safety and clinical outcomes of percutaneous sclerotherapy of venous disorders of the labia majora in patients with vascular malformations of the lower limbs. METHODS: Thirty percutaneous sclerotherapy treatments were performed over a 6-year period among 17 female patients with symptomatic venous malformation (VM) or secondary varicosis of the labia majora. Four patients were treated with sclerotherapy alone, 13 patients had additional procedures to control the VM before sclerotherapy. Polidocanol was used as sclerosant. Indications for sclerotherapy included pain, bleeding, thrombophlebitis, and swelling. Genitourinary symptoms were recorded. The number of treatments and procedure-related complications were registered. Complications were classified according to the Society of Interventional Radiology (SIR) classification system (grade A-E). The 3-month postintervention follow-up included magnetic resonance imaging, clinical examination, and a symptom-related questionnaire. If no reintervention was necessary, consultation was scheduled biannually. RESULTS: All patients had local swelling and pain; only a fraction of the patients had further symptoms with bleeding or thrombophlebitis (47% each). Eight patients required reintervention. No major complications were observed; minor complications such as postprocedural swelling occurred in 29% (SIR grade A), pain occurred in 17% (SIR grade B), and skin blistering developed in 5% (SIR grade B). Upon follow-up examination after a median of 40 months, 76% showed complete relief of symptoms, and 23% reported partial relief. All patients reported a substantial reduction in pain (75% >5 points in visual analogue scale) and swelling (88% complete cessation). CONCLUSIONS: Percutaneous sclerotherapy is a safe and effective treatment option of VM and secondary varicosis of the labia majora.

Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause.

Objective: This study aims to investigate the mechanism of action of pelvic floor muscle training (PFMT) for the improvement of the signs and symptoms of genitourinary syndrome of menopause (GSM) in postmenopausal women with GSM and urinary incontinence (UI).Methods: Twenty-nine women were included in the secondary analysis of a single-arm feasibility study. Using color Doppler ultrasound, the peak systolic velocity, time-averaged maximum velocity, and pulsatility index of the internal pudendal and dorsal clitoral arteries were measured at rest and after a pelvic floor muscle (PFM) contraction task. PFM function was assessed by dynamometry, and vulvovaginal tissue elasticity was measured using the Vaginal Atrophy Index.Results: PFMT significantly improved blood flow parameters in both arteries (p < 0.05) and significantly increased the speed of PFM relaxation after a contraction (p = 0.003). After the intervention, a marginally significant decrease in PFM tone was observed, as well as an increase in PFM strength (p = 0.060 and p = 0.051, respectively). Finally, improvements in skin elasticity and introitus width were observed as measured by the Vaginal Atrophy Index (p < 0.007).Conclusion: Our findings suggest that PFMT improves blood flow in vulvovaginal tissues, PFM relaxation capacity, and vulvovaginal tissue elasticity in postmenopausal women with GSM and UI.

A randomized single-blind placebo-controlled study of a Visnadine Emulgel formulation on healthy postmenopausal women.

BACKGROUND: There is a growing interest on women' sexual function improvement provided by topical vulvar application of Visnadine, a natural extractive substance with putative vasodilatory properties. Aims of this study were to evaluate: 1) the vasokinetic activity of a Visnadine Emulgel on mucosal genitalia of 15 healthy postmenopausal women clinically and by instrumental non-invasive analysis; 2) the treatment efficacy by volunteers' judgment regarding to subjective comfort, pleasant warmth, lubrication grade, pinching and burning vulvar sensations. METHODS: Fifteen informed healthy female volunteers with menopause were enrolled in the study, with a single blind controlled study versus placebo corresponding to one single application of the emulgel product (active or placebo) on external genitalia. RESULTS: Visnadine Emulgel single application determined a significant increase of vulvar hyperemia, evaluated both clinically and instrumentally, accompanied by a significant increase of local turgor versus placebo. The volunteers reported a pleasant comfort sensation. CONCLUSIONS: The topical use of Visnadine on female external genitalia may increase regional vascularization affecting turgidity and sensorial threshold of the area of application.

Does pelvic congestion syndrome influence symptoms of chronic venous disease of the lower extremities?

OBJECTIVE: The study was aimed at assessing the influence of pelvic congestion syndrome (PCS) on the clinical manifestations of chronic venous disease (CVD) of the lower extremities in patients with concomitant varicose veins of the pelvis and lower extremities. STUDY DESIGN: We examined clinically and with duplex ultrasound 30 women with varicose veins of the lower extremity only (VVLE) and another 45 women with VVLE and concomitant varicose veins of the pelvis (VVP) causing symptoms of the pelvic congestion syndrome (PCS). All patients had chronic venous disease (CVD) of class C2 (n = 47) or C3 (n = 28) according to the CEAP classification. All patients underwent duplex ultrasound (DUS) of the lower extremities and pelvis. Based on the clinical examination and DUS findings, the patients were allocated into two groups: group 1 (n = 30 patients with isolated VVLE without the signs of PCS and pelvic veins lesions) and group 2 (n = 45 patients with concomitant PCS, VVP and VVLE). The rates and severity of varicose, pain, and edema syndromes, and leg heaviness were assessed. RESULTS: The patients of the group 2 had significantly more severe clinical manifestations of CVD, 4 times higher risk of leg pain (odds ratio [OR] 4.23; 95% CI 1.57-11.39), 7 times higher risk of leg edema (OR 7.42; 95% CI 2.23-24.78), 5 times higher risk of leg heaviness (OR 5.3; 95% CI 1.85-15.07), and in general 2 times more severe varicose veins, compared with the group 1. CONCLUSION: The PCS is associated with an increase in the incidence and severity of the CVD symptoms.

Reduction of Hypertrophic Labia Minora by Posterior-Lateral Wedge Resection with Preservation of the Central Blood Vessels and Nerve Bundle.

OBJECTIVE: The aim of this study was to introduce a new method of labiaplasty. Here, we describe the surgical procedure, outcomes and the advantages of this method. METHOD: The medical records of 21 patients aged between 20 and 45 years who underwent reduction of the labia minora from February 2015 to June 2017 were reviewed. The procedures performed in these studies used posterior-lateral wedge resection with preservation of the central blood vessels and nerve bundle. RESULTS: All the surgeries were performed successfully, and 21 patients experienced an uneventful postoperative period. A minor dehiscence occurred in one patient, who recovered with no requirement for additional treatment. All of the patients were satisfied with the eventual esthetic appearance. CONCLUSION: The posterior-lateral wedge resection with preservation of the central blood vessels and nerve bundle is a simple and safe method that is associated with satisfactory outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.

Reliability of vulvar blood perfusion in women with provoked vestibulodynia using laser Doppler perfusion imaging and laser speckle imaging.

BACKGROUND: Microvascular assessment has become increasingly used in gynecology to better understand the pathophysiology of various vulvar conditions and to study sexual function. Alteration in blood perfusion of the vulvar area has been observed using laser technologies in women with provoked vestibulodynia (PVD), the leading cause of vulvar pain. However, no studies have thus far investigated the reliability of and agreement between lasers for evaluating vulvar blood perfusion. OBJECTIVES: The main objective was to investigate the between-session reliability of the laser Doppler perfusion imaging (LDPI) and laser speckle contrast imaging (LSCI) for assessing blood perfusion of the vulvar vestibule in women with PVD. Secondary aims were to evaluate the association and agreement between the two laser technologies. METHODS: Twenty-six women with PVD participated in the study. Blood perfusion of the vulvar vestibule was assessed with LDPI and LSCI during two sessions 2 to 4 weeks apart. Blood perfusion was analyzed in five specific areas of the vulvar vestibule: 1) 3 o'clock site, 2) 6 o'clock site, 3) 9 o'clock site, 4) central area (delimited by areas 1, 2 and 3), and 5) posterior fourchette. The reliability of the measurements of the two instruments was calculated with intraclass correlation coefficients (ICCs), standard errors of measurement (SEMs) and coefficients of variation (CVs). Paired t-tests were also computed to compare the CVs of each laser technology. The association and agreement between LDPI and LSCI measurements were evaluated by Pearson's correlation coefficients and Bland-Altman plots, respectively. RESULTS: Excellent reliability was found for LDPI (ICCs = 0.78-0.80, p < 0.001, SEMs = 16.1-47.9) and LSCI measurements (ICCs = 0.75-0.81, p ≤ 0.001, SEMs = 17.0-52.2) for all vulvar vestibule areas. However, CVs were significantly higher using LDPI (CVs = 15.1-19.8) when compared to LSCI (CVs = 7.0-11.6) for all areas (p ≤ 0.031), except for area 4 (p = 0.079). Significant correlations were found between LDPI and LSCI for all areas (r = 0.58-0.89, p ≤ 0.003). Bland-Altman plots revealed a systematic difference between LDPI and LSCI measurements. CONCLUSION: Findings show that both LDPI and LSCI measurements are reliable for assessing blood perfusion of the vulvar vestibule in women with PVD. The LSCI appears to be a more reliable measurement as it presents less variation than LDPI. Finally, although LDPI and LSCI measurements are related, the systematic difference observed between them makes it impossible to compare absolute units.

Internal iliac artery balloon occlusion as a hemostatic method for spontaneous rupture of vulvar hematoma during delivery: A case report.

Spontaneous rupture of a vulvar hematoma during delivery is a relatively uncommon event and may cause excessive hemorrhage. Exact identification of anatomic structures and bleeding points is challenging. We herein present a case involving a pregnant woman at 39 weeks' gestation with a large vulvar hematoma that spontaneously ruptured during the second stage of labor, likely due to rupture of varices in the vulva or vagina. It was difficult to accurately expose and suture the deep bleeding points. The estimated blood loss volume was 1591 mL, and the hemoglobin concentration dropped from 132 g/L before delivery to 84 g/L after delivery. To prevent hemorrhagic shock, bilateral internal iliac artery balloon occlusion was performed and proved to be an effective way to achieve hemostasis. Once hemostasis was established, ligation of the bleeding sites and suturing of all dead space were rapidly completed. Bilateral internal iliac artery balloon occlusion can be used as an effective treatment for excessive vaginal bleeding. The presence of varices or hemangiomas in the vulva or vagina should be carefully checked during antenatal care.

Sensitivity and specificity of clinical findings for the diagnosis of pelvic congestion syndrome in women with chronic pelvic pain.

Background Pelvic congestion syndrome is among the causes of pelvic pain. One of the diagnostic tools is pelvic venography using Beard's criteria, which are 91% sensitive and 80% specific for this syndrome. Objective To assess the diagnostic performance of the clinical findings in women diagnosed with pelvic congestion syndrome coming to a Level III institution. Methods Descriptive retrospective study in women with chronic pelvic pain taken to transuterine pelvic venography at the Advanced Gynecological Laparoscopy and Pelvic Pain Unit of Clinica Comfamiliar, between August 2008 and December 2011, analyzing social, demographic, and clinical variables. Results A total of 132 patients with a mean age of 33.9 years. Dysmenorrhea, ovarian points, and vulvar varices have a sensitivity greater than 80%, and the presence of leukorrhea, vaginal mass sensation, the finding of an abdominal mass, abdominal trigger points, and positive pinprick test have a specificity greater than 80% when compared with venography. Conclusion This study may be considered as the first to evaluate the diagnostic performance of the clinical findings associated with pelvic congestion syndrome in a sample of the Colombian population. In the future, these findings may be used to create a clinical score for the diagnosis of this condition.

Randomized crossover study investigating daily versus on-demand vulvar Visnadine spray in women affected by female sexual arousal disorder.

The aim of the study was to verify the efficacy of vulvar Visnadine spray in premenopausal women affected by female sexual arousal disorder (FSAD). Thirty-eight women aged 25-40 years affected by FSAD were enrolled in the randomized crossover study, by two possible sequences: on-demand, washout, daily (A sequence); and daily, washout, on-demand (B sequence). The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess sexual function and sexual distress, respectively. Color Doppler ultrasonography was used to measure clitoral blood flow. The study had two follow-ups at 30 (T1) and 60 days (T2). Thirty-one women completed the study. Mean (SD) sexual activity and vulvar Visnadine spray usage was 1 ± 0.9 weekly during on-demand administration for both the sequences (Vs T0, p = NS). The mean sexual activity during daily usage was 2 ± 0.9 (Vs T0, p < .004) and 2 ± 0.8 (Vs T0, p < .001) for A and B sequences, respectively. FSFI total score, particularly genital arousal, improved more during the daily than during on-demand phases of both sequences (p < .001). Finally, clitoral blood flow improved significantly during daily usage of both the sequences (p < .001). Our study suggests that vulvar Visnadine spray could improve sexual performance of women affected by FSAD, producing changes in subjective and objective sexual aspects.

Short communication: Repeatability of ß-hydroxybutyrate measurements in capillary blood obtained from the external vulvar skin.

The primary objective of this study was to evaluate the repeatability of measurements of ß-hydroxybutyrate (BHB) concentrations in capillary blood obtained from minimal-invasive puncturing of different sites at the external vulva skin of dairy cows. A total of 240 multiparous cows sampled once within 21 d in milk were enrolled in the study. Capillary blood samples were obtained from the right and left labium of the external vulva skin and additionally from a site close to the first puncture. Samples were analyzed by using an electronic hand-held device [FreeStyle Precison Neo (FSP-Neo), Abbott GmbH & Co., Wiesbaden, Germany)]. Additionally, samples from a coccygeal vessel were analyzed as reference in a laboratory. Mean deviations (± standard deviation) between the 3 capillary sampling sites ranged from 0.01 ± 0.14 (left vs. right labium) to 0.02 ± 0.13 mmol/L (left or right labium vs. additional site). The BHB concentrations in capillary blood compared with the reference showed a mean deviation of 0.14 ± 0.18 mmol/L. The Spearman correlation coefficient between BHB concentrations in capillary blood and coccygeal blood was 85.4%. Mixed model analyses showed no significant effect of sampling site or squeezing the skin during sampling procedures on the differences toward the reference. Based on laboratory BHB concentrations of ≥1.2 and ≥1.4 mmol/L, respectively, the prevalence of hyperketonemia was 10.4 (n = 25) and 5.0% (n = 12). Thresholds to detect hyperketonemia with the FSP-Neo were optimized by receiver operating characteristic analyses. Based on a laboratory BHB concentration of ≥1.2 mmol/L thresholds were determined as 1.1 (left labium, 2nd puncture) and 1.0 mmol/L (right labium), with sensitivities between 94 and 99% and specificities between 89 and 97%. Based on a serum BHB concentration of 1.4 mmol/L, receiver operating characteristic analyses resulted in optimized cutoffs of 1.4 mmol/L for all sampling sites at the vulva, with sensitivities of 100% and specificities between 96 and 99%. In conclusion, vulvar capillary blood is suitable for accurate measuring of BHB concentrations by using the FSP-Neo. After adjusting the thresholds, the FSP-Neo provides very good test characteristics independent of the capillary sampling site or squeezing the skin and allows a practical and reliable screening tool for dairy cows.

Vulvar Varicosities: A Review.

BACKGROUND: Vulvar varicosities (VV) are dilated and tortuous veins occurring within the external female genitalia. Patients may seek treatment of these varices for both medical and cosmetic purposes. In some patients, VV may be associated with a chronic pelvic pain syndrome called pelvic congestion syndrome (PCS). OBJECTIVE: To review the English language literature on VV in both pregnant and nonpregnant women. MATERIALS AND METHODS: A literature search pertaining to vulvar varicosities and PCS was performed using PubMed and Google Scholar databases. RESULTS: There is an overall paucity of literature discussing VV, particularly in nonpregnant women without PCS. Management options for VV include compression, sclerotherapy, embolization, and surgical ligation. Treatment can be dependent on the coexistence of pelvic or leg varicosities and may require referral to a vein specialist for advanced imaging techniques and procedures. Direct sclerotherapy to VV may not provide adequate treatment if pelvic or leg varices are also present. CONCLUSION: In women with persistent VV, imaging studies should be obtained before treatment to evaluate the surrounding venous anatomy of the pelvis and leg, as the results often affect the treatment approach. Patients presenting with VV and chronic pelvic pain should be evaluated for PCS.

A Vulvovaginal Mass in a 16-Year-Old Adolescent: A Case Report.

BACKGROUND: Vulvar varicosities might be misdiagnosed as vulvar venous malformations in the prepubertal or pubertal age. If seen isolated, they can mimic other masses that are usually seen in this anatomic area like a hernia or a cyst. Depending on the associated symptoms and clinical findings, imaging modalities investigate the nature of such a mass and might provide a therapeutic alternative besides surgery. CASE: We report a case of an isolated asymptomatic vulvar varicosity in a 16-year-old adolescent. A pelvic ultrasound followed by a Doppler and a magnetic resonance imaging scan confirmed the diagnosis. We used guided direct sclerotherapy for successful treatment. SUMMARY AND CONCLUSION: Optimal management and outcome are assured using a multidisciplinary approach. Guided sclerotherapy provides a safe, effective, and minimally invasive procedure to treat vulvar varicosities.

Feasibility and Safety of Video Endoscopic Inguinal Lymphadenectomy in Vulvar Cancer: A Systematic Review.

OBJECTIVE: To systematically review previous studies and to evaluate the feasibility and safety of video endoscopic inguinal lymphadenectomy (VEIL) in vulvar cancer. METHODS: We conducted a comprehensive review of studies published through September 2014 to retrieve all relevant articles. The PubMed, EMBASE, Web of Science, Cochrane Library, Wan Fang Data and Chinese National Knowledge Infrastructure databases were systematically searched for all relevant studies published in English or Chinese through September 2014. Data were abstracted independently by two reviewers, and any differences were resolved by consensus. RESULTS: A total of 9 studies containing 249 VEIL procedures involving 138 patients were reviewed. Of the 249 VEIL procedures, only 1 (0.4%) was converted to an open procedure for suturing because of injury to the femoral vein. The range of operative time was 62 to 110 minutes, and the range of estimated blood loss was 5.5 to 22 ml. The range of the number of harvested lymph nodes was 7.3 to 16. The length of hospital stay varied from 7 to 13.6 days across reports. The incidence of lymph node metastasis was 19.7% (27/138), and the recurrence rate was 4.3% (3/70) within 3 to 41 months of follow-up. One or more short-term complications were documented in 18 of 138 (13.0%) patients. Complications after VEIL were observed in 14 (10.13%) patients and in 15 (6.0%) of the VEIL cases, including major lymphocyst formation in 9 (3.6%), lymphorrhea in 2 (0.8%), inguinal wound infection without wound breakdown in 3 (1.2%) and lymphedema in 1 (0.4%). CONCLUSIONS: VEIL appears to be a feasible procedure in the management of vulvar cancer. There may be potential benefits that result in lower morbidity compared to traditional methods, but this has yet to be objectively proven.