Male Patterns of Pelvic Venous Reflux can be Investigated with Duplex Ultrasound and Treated with Coil Embolization

Pelvic venous reflux (PVR) has been shown to be a cause of pelvic congestion syndrome, vulval and lower limb venous varicose veins in women. In men, it is usually only acknowledged as a cause of testicular varicocele. We report a clinical series of male patients with lower limb varicose veins in whom PVR was a major contributory factor. Eight male patients with bilateral lower limb varicose veins presented to our unit between March 2014 and July 2016; all legs were examined with duplex ultrasound (DUS), and a significant pelvic contribution to their reflux pattern was observed. Testicular and internal iliac veins were examined with testicular, transabdominal, or transrectal DUS, computed tomography, or magnetic resonance venography. Patients were referred for transjugular coil embolization under local anesthesia and treated according to their diagnostic imaging results. A minimum of 6 weeks after embolization, patients proceeded to treatment of their leg varicose veins. Reflux was either proven on DUS or indicated on nondynamic studies in 23 of 32 pelvic veins and was treated with coil embolization. All refluxing lower limb truncal veins were then treated with endovenous laser ablation and subsequent phlebectomies, with any remaining varicosities treated with ultrasound-guided foam sclerotherapy. Presently, three of eight patients have completed treatment and have been discharged; treatment is still ongoing in the remaining five cases. PVR is known to be a cause of primary and recurrent varicose veins in women. In men, the lack of transvaginal duplex ultrasound means that diagnostic imaging is far more challenging. We have reported a series of male patients in whom PVR was a major contributory cause of venous reflux and symptomatic varicose veins and reported treatment by transjugular coil embolization. Although the prevalence of PVR appears to be far lower in men than in women (approximately 1:30 male-to-female ratio in our overall series), no reliable epidemiologic data exist to substantiate this observation.