Download Diagnosis and Treatment of Pelvic Venous Syndromes

Volume 4, Issue 1
In This Issue
Diagnosis and Treatment of
Pelvic Venous Syndromes…..1
Demystifying the
Compression Rx.……..…...…...4
Q&A: Insurer Payment…..…...1
Venous Review Insert...…..5&6
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Venous Review
Editorial Staff
Editor-in-Chief
Sanjiv Lakhanpal, MD, FACS
Associate Editors
Robert Kiser, DO, MSPH
Shekeeb Sufian, MD, FACS
Contributing Manager
Robert Howell, MS
ISSN 2159-4767 (Print) , ISSN 2159-4775 (Online)
Diagnosis and Treatment of Pelvic Venous Syndromes
By Robert Kiser, DO, MSPH
Vulvar varicosities are a source of embarrassment and pain for many women but they
are often reluctant to discuss their condition or symptoms with their doctors. These
varicosities can easily be missed in casual examination, as they are less obvious in the
supine position and may not be seen until the patient stands or
assumes an upright sitting or squatting position.
When evaluating lower extremity varicose veins, varicosities in the
proximal inner thigh should prompt the physician to consider a
pudendal origin. The question, ―Do you have any varicose veins of
the vulva or labia?‖ should be asked as well as questions about
pelvic congestion symptoms. There are a variety of treatments that
can help to improve or eliminate these symptoms. To page 3 ►
Vulvar varicosities may occur as isolated tributary varicosities or may be a sign
of underlying pelvic venous insufficiency. They can also be associated with PCS.
———————————————————–--————————————————————————
Q: My patient has varicose veins and spider veins but is concerned
about her insurer paying for evaluation and treatment. Is this a
cosmetic procedure?
A: Most insurers, including Medicare, do pay for the evaluation and treatment of varicose veins
and venous insufficiency. Varicose veins are enlarged veins (>4mm) below the skin surface that
can be seen or felt. They are far more than a cosmetic problem, and can cause symptoms such as
pain, throbbing, leg fatigue, swelling, and in later stages, chronic rashes or open sores of the legs.
Managing Editor
Judith D. Grillo, MEd
Criteria vary by insurer, but most require that the patient have either symptoms of chronic venous
insufficiency (CVI) such as leg pain or fatigue, or signs of CVI such as swelling, erythema hyperpigmentation, varicose vein hemorrhage, ulcers, stasis dermatitis, phlebitis or other inflammatory
changes. Most insurers will not cover the treatment of telangiectasias, the thread-like red or blue
―spider veins‖ at the skin surface that are usually not palpable.
Copyright ©2011 Center for Vein Restoration.
All rights reserved.
We welcome your questions – email [email protected]. We do reserve the right to edit for publication.
Page 2
Venous Review
Demystifying the Compression Rx
Continued from Page 4
Writing the Rx
When writing a compression stocking prescription, the key
components are:
Graduated Compression Stockings.
The stocking should have a gradient pressure, with the
strongest pressure at the ankle and less pressure at more
proximal points of the lower extremity. Compression hosiery
is classified according to the pressure level applied at the
ankle in three classes: Class I=20-30mmHg; Class II=3040mmHg; Class III=40-50mmHg.4
Dispense Quantity.
One pair may be sufficient, however, if both stockings are
to be worn continuously during the day then 2 pair allows
for laundering.
Fit to the Patient.
To provide the correct compression, it is necessary that the
stocking be properly fitted by a trained fitter. Most durable
medical equipment providers have a trained fitter on staff.
Sig: Wear While Upright.
Patient may generally remove the stocking at bedtime.
Ideally the stocking should be donned prior to getting into
an upright position.
Dx.
Distributors and insurers will require a diagnosis for the
stocking order, such as 454.1 varicose veins with inflammation or 671.2 superficial thrombophlebitis or 453.40
venous embolism and thrombosis of unspecified deep
vessels of lower extremity.
Contraindications
Extensive wet dermatoses, burns or skin loss are obvious
contraindications. Another contraindication is significant
peripheral arterial disease (PAD). Avoid elastic compression
if the ankle brachial index (ABI) is 0.8 or less. Patients with
PAD are unlikely to tolerate strong compression, and there
is a risk of worsening ischemia provoking skin necrosis or
ulceration.5 As a rule of thumb, if the foot pulses are not
palpable, it is reasonable to obtain an ABI prior to stocking
prescription.
Insurance Requirements
Many insurers will cover treatment of symptomatic varicose
veins only after the patient has undergone a ―trial‖ of
graduated compression stockings. Exact requirements vary
but it is commonly a duration of 3 months using 20-30 or
30-40mmHg compression stockings.
Therefore, it is in the best interest of the patient with varicose veins to begin to wear graduated compression stockings as soon as possible. They will be able to get definitive
treatment sooner, while having an immediate reduction in
symptoms, swelling, and risk of thrombosis.
Length and Other Options
Choices in length include knee-high, thigh-high, pantyhose
and men’s leotard. Knee-high stockings are the easiest to
don, while thigh-high stockings are especially useful if the
patient has considerable pathology, such as large varicosities or phlebitis above the knee.
Pantyhose or leotards are preferred by those who have
large thighs with redundant adipose that causes the thighhigh stocking to creep downward. They may also be of
some benefit for patients with gluteal, and to a lesser
extent, pudendal varicosities.
Compression stockings come in a wide variety of colors,
sheerness, and many styles. Taking these niceties into
consideration can help to improve patient compliance with
stocking use.
The Center for Vein Restoration offers comprehensive care
for venous disease. Call 1-800-FIX-LEGS or 301-860-0930.
References
1. Miyamoto N, Hirata K, Mitsukawa N, Yanai T, Kawakami Y. Effect of
pressure intensity of graduated elastic compression stocking on muscle
fatigue following calf-raise exercise. J Electromyogr Kinesiol. 2010 Sep 13.
http://www.ncbi.nlm.nih.gov/pubmed/20843703
2. Olson JM, Raugi GJ, Nguyen VQ, Yu O, Reiber GE. Guideline concordant
venous ulcer care predicts healing in a tertiary care Veterans Affairs Medical Center. Wound Repair Regen. 2009 Sep-Oct; 17(5):666-70. http://
www.ncbi.nlm.nih.gov/pubmed/19769720
3. Bogachev VIu, Shekoian AO. Pain and other symptoms of chronic venous diseases: pathophysiology and therapeutic principles. Angiol Sosud
Khir. 2009;15(3):79-85. http://www.ncbi.nlm.nih.gov/
pubmed/20092187
4. Moses, S. Family Practice Notebook, October 2010, Family Practice
Notebook, LLC, Minnesota. http://www.fpnotebook.com/surgery/pharm/
cmprsnstckngs.htm
5. The Joanna Briggs Institute. Graduated compression stockings for the
prevention of postoperative venous thromboembolism. Best Practice:
evidence-based practice information sheets for health professionals
2001;5(2):1-6. http://www.joannabriggs.edu.au/pdf/
BP_Book_Vol12_4.pdf
——————————————————
Patients will find compression garments
in a wide variety of colors and styles
at a price they can afford
at Legsmatter.com.
To order by phone,
call 1-888-997-9976.
Page 3
Volume 4, Issue 1
Diagnosis and Treatment of Pelvic Venous Syndromes
Continued from Page 1
Background and Epidemiology
Vulvar varicosities occur in an estimated 4% of women1 and 15.8-23% of those with
lower extremity varicose veins2,3. Most occur during pregnancy and resolve within a
few months. When they do not resolve they may cause symptoms of pain, itching,
burning, dysparunia, and are perceived by some women as a cosmetic nuisance.
“Pelvic Congestion Syndrome results from
venous insufficiency of the ovarian veins, and
is often under-diagnosed.”
Vulvar varicosities may occur as isolated tributary varicosities or may be a sign of underlying pelvic venous insufficiency.
They can also be associated with Pelvic Congestion Syndrome (PCS). PCS results from venous insufficiency (reflux) of the
ovarian veins. This important but under-diagnosed condition is associated with symptoms of dysparunia, chronic pelvic pain,
feeling of pelvic fullness and discomfort4.
When signs or symptoms of PCS are reported, a diagnostic transvaginal ultrasound both supine and standing, with and
without Valsalva may be ordered to quantify pelvic vein reflux. Magnetic resonance venography is also extremely sensitive
to finding dilated gonadal veins and provides an abundance of anatomic information 5. Consultation with an interventional
radiologist or vascular surgeon for venography and possible coil embolization or fluoroscopy-guided sclerotherapy is
warranted when found.
Compression Therapy
Any patient with symptomatic vulvar varicosities (pregnant or not) should be encouraged to try compression therapy. The
company, Prenatal Cradle, makes the V-2 Supporter for the pregnant or non-pregnant woman with vulvar varicosities. This
device is similar in appearance to a male athletic supporter, but is contoured to provide compressive support for the vulva,
thus preventing the pooling of blood in the labial veins6.
Non-surgical and Minimally Invasive Techniques
For vulvar varicosities in the non-pregnant patient, remarkable improvement can be achieved with sclerotherapy. The visible
varicosities are injected with a quantity of liquid or foam sclerosant, and the area is then compressed with a pad and the
V-2 supporter or similar compression garment7. A few treatments can provide lasting relief and cosmetic improvement in
vulvar varicosities. To minimize the risk of complications, the injecting physician should have extensive experience with vein
sclerosis and a strong working anatomy of the pelvic venous system.
Persistent Pelvic Congestion Syndrome
For some patients, treatment of vulvar varicosities with a V-2 compression trial followed
by compression sclerotherapy affords symptomatic improvement 8. Patients with PCS who
are not responding to compression should be evaluated by an interventional radiologist
or vascular surgeon for possible coil embolization. Under fluoroscopy guidance, the
refluxing ovarian veins can be embolized by endovenous insertion of a metallic coil.
Under fluoroscopy guidance, patients
with PCS can be embolized by
endovenous insertion of a metallic coil.
Photo courtesy of Boston Scientific.
After the pelvic venous insufficiency has been treated, if not previously addressed, the
vulvar varicosities may be re-evaluated by a phlebologist who practices sclerotherapy to
determine whether the varicosities and their associated symptoms have adequately
resolved. If not, sclerotherapy of the visible varicosities may be provided if the patient
wishes.
Help is available for your patients suffering with Pelvic Venous Syndromes. For more
information, call 1-800-FIX-LEGS or 301-860-0930.
References
1. Bell D, Kane PB, Liang S, Conway C, Tornos C. Vulvar varices: an uncommon entity in surgical pathology. Int J Gynecol Pathol. 2007 Jan;26(1):99-101.
http://www.ncbi.nlm.nih.gov/pubmed/17197905.
2. Dodd, H, Wright, P. Vulval Varicose Veins in Pregnancy. Br Med J. 1959 Mar 28. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824/pdf/
brmedj02964-0039.pdf.
3. Ashour MA, Soliman HE, Khougeer GA . Role of descending venography and endovenous embolization in treatment of females with lower extremity varicose veins, vulvar and posterior thigh varices. Saudi Med J. 2007 Feb;28(2):206-12. http://www.ncbi.nlm.nih.gov/pubmed/17268690.
4. Freedman J, Ganeshan A, Crowe PM. Pelvic congestion syndrome: the role of interventional radiology in the treatment of chronic pelvic pain. Postgrad
Med J. 2010 Dec;86(1022):704-10. http://www.ncbi.nlm.nih.gov/pubmed/21106807.
5. Freedman J, et al. Postgrad Med J., 704-10. http://www.ncbi.nlm.nih.gov/pubmed/21106807.
6. Seering, C. The V2 Supporter provides clinically proven compression therapy. Prenatal Cradle, Hamburg, MI. Available: http://www.prenatalcradle.com/
v2.htm.
7. Freedman J, et al. Postgrad Med J. 704-10. http://www.ncbi.nlm.nih.gov/pubmed/21106807.
8. Paraskevas P. Successful ultrasound-guided foam sclerotherapy for vulval and leg varicosities secondary to ovarian vein reflux: a case study. Phlebology.
2010 Nov 12. http://www.ncbi.nlm.nih.gov/pubmed/21075823.
Venous Review—The Official Journal of the Center for Vein Restoration
7300 Hanover Drive, Suite 104
Greenbelt, MD 20770
Ph: 1-800-FIX-LEGS/301-860-0930
www.centerforvein.com
Our Locations
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Prince Frederick, MD
Rockville, MD
Takoma Park/Silver Spring, MD
Waldorf, MD
Washington, DC
Coming soon to:
Columbia, Maryland
Demystifying the Compression Rx
By Robert Kiser, DO, MSPH
For a patient with venous disease, one of the more
important and useful prescriptions a physician can write is
for compression stockings. Patients who will benefit from
graduated compression therapy include those suffering
from:
Superficial venous insufficiency or varicose veins
Phlebitis, DVT or pulmonary embolism, or at risk of the same
Lymphedema
Leg fatigue, aching, or end-of–day edema
Varicosities resulting from pregnancy
Compression therapy works by applying controlled pressure
to the surface veins, keeping their diameter small, and
forcing blood back into the deep vein system. For patients
with venous disease, compression therapy may offer many
of these benefits:
Improve stamina1
Speed healing of ulcers and wounds2
Reduce edema
Help reduce pain of superficial phlebitis and varicosities3
Augment calf-pump to reduce venous stasis
Reduce the risk of venous thrombosis
Compression Therapy Guide
Class I
Class II
Class III
20-30mmHg
30-40mmHg
40-50mmHg
-Moderate to severe
varicosities
-Post-surgical
-Moderate edema
-Post-sclerotherapy
-Helps prevent recurrence
of venous ulcerations
-Moderate to severe
varicosities during
pregnancy
-Superficial thrombophlebitis
-Helps prevent DVT
-Severe varicosities
-Severe edema
-Lymphatic edema
-Management of active
venous ulcerations
-Helps prevent recurrence
of venous ulcerations
-Manage manifestations
of PTS
-Helps prevent PTS
-Orthostatic hypotension
-Post-surgical
-Post-sclerotherapy
-Helps prevent DVT
-Chronic venous
insufficiency
-Severe varicosities
-Severe edema
-Lymphatic edema
-Management of
active venous ulcerations
-Manage manifestations
of PTS
-Orthostatic hypotension
-Postphlebitic syndrome
-Chronic venous
insufficiency
Writing the Compression Rx, To page 2 ►
Center for Vein Restoration
Opens in the Kalamazoo/Portage,
Michigan Area
an experienced practitioner of perforator vein closure
and diagnostic ultrasound.
The Center for Vein Restoration, a nationally recognized
vein center specializing in the treatment of varicose and
spider veins recently opened in Kalamazoo/Portage,
Michigan.
Board-certified in Phlebology, Dr. Kiser has been a
Diplomate of the American Board of Phlebology since its
inception in 2008. He is an active member of the American
College of Phlebology and the American Venous Forum,
and serves on the American College of Phlebology’s
Research Committee.
Robert C. Kiser, DO, MSPH joins the
clinically award-winning team of cardiothoracic surgeons, vascular surgeons, and
phlebologists to lead the Center for Vein
Restoration clinic in the Kalamazoo area.
Office-based procedures, covered by most insurance plans,
are now being offered at the Kalamazoo/Portage location.
To schedule a free screening or appointment, call 1-800FIX-LEGS (800-349-5347).
Robert Kiser, DO, MSPH
―The Center’s philosophy of caring,
compassion and clinical excellence is
what attracted me most,‖ he says.
Dr. Kiser grew up in Kalamazoo, Michigan, and attended
the University of Michigan in Ann Arbor, graduating with
honors. In 1993, he graduated from Michigan State
University College of Osteopathic Medicine, and
completed an internship in Family Practice at Riverside
Osteopathic Hospital in Trenton, Michigan. Dr. Kiser’s
residency followed in General Preventive Medicine and
Public Health at the University of Colorado Health
Sciences Center in Denver, where he also obtained a
Master’s of Science in Public Health.
In 2003, Dr. Kiser underwent intensive training in the
diagnosis and treatment of venous disease and began
a full-time Phlebology practice in Mishawaka, Indiana
and Okemos, Michigan. He served as the Director of
Medical Consultation and Research for the largest vein
practice group in the state of Indiana.
During this time, he successfully treated men and
women with varicose veins, venous ulcers, and spider
veins. Dr. Kiser uses a variety of effective, minimallyinvasive treatment methods including injection and
ultrasound-guided sclerotherapy, endovenous laser
ablation, and ambulatory micro-phlebectomy. He is also
Center for Vein Restoration
Woodbridge Hills
3810 West Centre Avenue, Suite A
Portage, Michigan
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Physicians and their medical staff are at
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If you’re a physician or medical office staff
member who may be suffering from venous
insufficiency, we can help.
Schedule a free screening by calling 1-800FIX-LEGS (800-349-5347) or
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