Indian Journal of Vascular and Endovascular Surgery

: 2018  |  Volume : 5  |  Issue : 4  |  Page : 234--243

Ultrasound assessment of pelvic venous reflux

Angie M White, Judy M Holdstock 
 Whiteley Clinics, London, UK

Correspondence Address:
Dr. Angie M White
Whiteley Clinics, London

How to cite this article:
White AM, Holdstock JM. Ultrasound assessment of pelvic venous reflux.Indian J Vasc Endovasc Surg 2018;5:234-243

How to cite this URL:
White AM, Holdstock JM. Ultrasound assessment of pelvic venous reflux. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2021 Jan 27 ];5:234-243
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This is the Whiteley Clinic Protocol for diagnosing pelvic venous reflux in females. A three-part ultrasound examination of transabdominal (TADUS), transvaginal (TVDUS), and translabial (TLDUS) is utilized to gain a full diagnostic picture of the inferior vena cava (IVC), bilateral renal vein (right renal vein [RRV] and left renal vein [LRV]), ovarian vein (OV; right OV [ROV] and left OV [LOV]), common iliac vein (CIV; right CIV and left CIV [LCIV]), internal iliac vein (IIV; right IIV [RIIV] and left IIV [LIIV]), and external iliac veins (EIV; right EIV and left EIV). Since 2000, we have performed TVDUS and TLDUS for evaluation of pelvic reflux,[1] while other groups have described a purely transabdominal technique.[2] In 2016, we introduced TADUS alongside our existing protocol. We feel that this three-part examination provides additional anatomical information useful for guidance during pelvic vein embolization (PVE), while keeping with the high diagnostic level of transvaginal imaging. As with leg varicose veins, there are many various pelvic vein patterns. Pelvic reflux is relatively common in women. However, true compression syndromes are relatively rare in our experience.

The primary goal of the examination is to assess for venous reflux, which is described generally as reversal of flow in the venous system. Reflux is graded on a scale of 1 to 4:

AbsentNot significant (mild, intermittent reflux, lasting <0.5 s)Significant (persistent reflux lasting either the entire length of physical maneuvers as described below or for ≥0.5 s)Very significant (passive reflux or reflux lasting past the physical maneuver).

Other findings may include the following:

Trunk diameter ≥5 mm. Smaller trunks with persistent reflux should be considered as it has been shown that diameter does not indicate reflux with confidence[3]Venous trunks exhibit filling/dilation with physical maneuvers as well as refluxContralateral or ipsilateral siphon effects between OVs and IIVs. Siphon effects are seen with significant reflux in one trunk, with a corresponding suction effect with increased antegrade flow in an opposing trunk. This can be seen either passively or with physical maneuversAssociated varices exhibit filling/distension and flow reversal on physical maneuvers.

It is also important to evaluate for venous compression or scarring within the pelvic-associated venous system. Compression pathologies most commonly known are nutcracker phenomenon (NCP), in which LRV is compressed between aorta and superior mesenteric artery (SMA), and iliac vein compression, in which LCIV is compressed between proximal right common iliac artery and spine. Either of these two phenomena can occur with or without symptoms and their associated syndromes: nutcracker syndrome and May–Thurner syndrome. Other types of extrinsic compressions or congenital anomalies may be seen, and therefore, it is important to correlate overall patient presentation and symptoms with ultrasound findings. If findings do not fit with presentation, consider other pathologies.

 Patient Preparation

To increase diagnostic efficacy of the ultrasound, it is important to minimize the presence of bowel gas. The following patient preparation is advised:

24 h before examination

Consumption of low fiber/low gas-producing dietAvoidance of carbonated beverages and a limit of smoking and chewing gum if possible.

At least 4 h before examination

No food to be taken by mouth. Clear, nongaseous fluids are recommended to maintain normal hydration (will enhance imaging due to appropriate dilatation of the venous system).


Oral administration of simeticone, an antifoaming agent for use in reduction in bowel gasTimings for administration: evening before the examination at mealtime and bedtime and upon waking in the morning (or several hours before an afternoon examination) (Note: follow medication instructions and warnings. Not to be used if allergic or during pregnancy).

 Patient History

Obtain a detailed obstetric, gynecological, and venous history to include the following:

Number of pregnancies and mode of delivery (normal vaginal delivery, trial of labor, or cesarean section)History of gynecological or urological disease, investigations, or surgeryCurrent symptoms associated with pelvic congestion syndrome and their severity (as previously discussed), as well as their evolutionHistory of venous disease, investigations, or surgery, as well as current venous state of the legs.

 The Ultrasound Examination

Transabdominal ultrasound

Patient position

Initial position is nearly sitting (80° recumbent) to assess upper abdominal veins [Figure 1]. As it is similar to standing position during lower extremity venous duplex for reflux assessment, gravity and hydrostatic pressure will aid in demonstrating reflux. It is also thought that a true NCP will be more clearly visualized.[4] The patient is then reclined to 45° for veins at or below the umbilicus for ease in visualization.{Figure 1}

Equipment and settings

A curvilinear transducer is preferred (C5-1, Philips Healthcare, Bothell, Washington, USA) with the system optimized for high-resolution imaging of abdominal vasculature. Resolution should be set as a preference over frame rate, with the highest frequency selected for penetration needed. Color pulse repetition frequency (PRF) should be optimized for moderate-to-low velocity flow (10–15 cm/s).

Standard protocol

Ensure a light scan pressure is used, especially when evaluating for compression, as the vein wall can be extrinsically compressed easily due to wall pliability and low pressure within the lumen [Figure 2]. A thorough evaluation with the following views should be undertaken:{Figure 2}

Left renal vein

Rule out underlying NCP. LRV can course anteriorly between SMA and aorta (mesoaortic LRV [MA-LRV]), posteriorly between the aorta and spine (retroaortic LRV [RA-LRV]), or both. Pay close attention for collaterals that may drain into LRV, as there are many variants of drainage from LOV. Follow collaterals as distally as possible. Physical maneuvers, as described below, can be used to rule out true pathology.

Measure Widest anterior to posterior (A-P) diameters of the hilar segment of the LRV (H-LRV), MA-LRV, and/or RA-LRV [Figure 3]. Calculate ratio of H-LRV: MA-LRV and/or H-LRV: RA-LRV. A ratio of ≥5:1 can be indicative of NCP;[5] however, we have shown that elevated ratios can be seen in patients with significant proximal LOV reflux. In these cases, narrow A-P diameters of MA-LRV represent a “pseudo-nutcracker” phenomenon, caused by siphon effect of LOV reflux, rather than true anatomical pathology.[6] In our experience, a true NCP is very rareA longitudinal view of MA-LRV can provide valuable information about the structure of the vein [Figure 4], with a narrow craniocaudal width seen in true NCPUse color flow Doppler (CFD) on H-LRV and MA-LRV; check for direction of flow and fill. With significant proximal LOV reflux, MA-LRV may be underfilled due to LOV siphonFollowing with diagnostic criteria introduced by several authors,[5] measurements of H-LRV and MA-LRV velocities and angle of SMA to aorta can be taken. However, in our experience, we have found little correlation between these measurements and true NCP.{Figure 3}{Figure 4}

Right renal vein

Evaluate to provide comparison to the contralateral vein. Anomalies in anatomical presentation, such as duplicate RRV or ROV insertion into RRV rather than IVC, are noted.

Bilateral ovarian veins

ROV and LOV can be seen, even without dilatation, on most patients who are well prepped. To locate ROV, start with IVC in transverse at RRV level. Proximal ROV will be seen with a slow caudal sweep, typically inserting around 10:00 on a clock face [Figure 5], 1–2 cm below RRV. For LOV, start with LRV in transverse, and again scan slowly caudally. Unless there is collateralization, it will be the only vein seen joining LRV on the caudal surface. Follow both OVs distally into the pelvis, noting collateral vessels or anomalous anatomy which will be useful for access guidance during PVE. Distally, they can be seen draping over the iliac veins, originating from the ovaries [Figure 6].{Figure 5}{Figure 6}

Use both grayscale and CFD, noting diameter and flow direction in a longitudinal plane [Figure 7]a and [Figure 7]b. Maneuvers (as below) can be used to elicit reflux if not seen passively. Note location of insertions of ROV into IVC and LOV into LRV, as well as any collateral vessels or anomalous anatomy.{Figure 7}

Inferior vena cava and common iliac veins

Image IVC and CIVs in their entirety, both with grayscale and CFD. Note any abnormalities, narrowing, or scarring. Carefully evaluate proximal LCIV as this is a common site for extrinsic compression. Again, a light scan pressure should be utilized [Figure 8]. For LCIV imaging:{Figure 8}

Evaluate with grayscale in both longitudinal and transverse as the LCIV courses between right common iliac artery and spine [Figure 9]. A compression can be indicated with significant narrowing [Figure 10] as well as venous dilatation just distal to the constrictionColor aliasing or absence of CFD will likely be seen at a site of compression, with underfill distally due to slow flowEvaluate with spectral Doppler for phasic and spontaneous flow (ensure angle is corrected to ≤60°) [Figure 11]. Increased velocities and loss of phasicity may be representative of underlying compressionAgain, physical maneuvers can be utilized to rule out physiology versus pathology (see below).{Figure 9}{Figure 10}{Figure 11}

Bilateral external iliac veins

Check for narrowing and signs of obstruction with grayscale. CFD can assist to evaluate for webbing or scarring. Assess for symmetric phasic and spontaneous flow with spectral Doppler. Again, maintain light scan pressure.

Bilateral internal iliac veins

Follow the EIVs in longitudinal cranially, IIVs will come into view mid-pelvis [Figure 12]. If significant bowel gas is in the area, move the transducer lateral to EIV in the mid-pelvis and angle the probe medially with deep pressure. Anatomical representation of tributaries is seen in [Figure 13].{Figure 12}{Figure 13}

Utilize a heavy scan pressure as they are not commonly compressed by the transducer (due to their depth)Evaluate direction of flow with CFD [Figure 14]Use physical maneuvers as belowImage IIVs and tributaries into the deep pelvis and note communication into the lower extremities or groin.{Figure 14}

Kidneys and bladder area

Evaluate for symmetrical renal size and for any pathology. If TVDUS cannot be performed, evaluate periurethral and bladder area for refluxing varices.

Physical maneuvers

Venous flow is dynamic and changes with body position and normal physiological processes. With suspicion of venous compression or obstruction, several maneuvers can be utilized to determine physiology versus physiology.

Narrow MA-LRV diameter seen sitting is likely physiological if any of the below positions or maneuvers result in a diameter increase:

Lateral decubitus (right lateral decubitus, left lateral decubitus [LLD]) positionTrendelenburg position (useful with “pseudo-nutcracker” NCP to mitigate effects of gravity and hydrostatic pressure) [Figure 15]a,[Figure 15]b,[Figure 15]cDeep inspiration [Figure 16]Valsalva.{Figure 15}{Figure 16}

For suspicion of LCIV compression or obstruction, LLD or deep inspiration can dilate a narrowing if it is physiological.

Use Valsalva (simulates proximal compression) or a Kegel squeeze (simulates distal compression) when assessing OVs, IIVs, and any associated varices to elicit reflux if not seen passively.

Transabdominal ultrasound only

If a patient cannot tolerate transvaginal scanning, the most distal segments of OVs and IIVs must be carefully evaluated and followed as deep into the pelvis as possible.

Transvaginal ultrasound

TVDUS is extremely useful for assessing patterns of distal reflux and communication to lower extremities due to its high resolution (in comparison with TADUS). Make a full assessment of distal OVs and IIVs, communicating tributaries, contra- and ipsi-lateral shunting, and pelvic varices.

Patient position

Semirecumbent with head reclined to 45°. A bolster cushion may be required to allow full manipulation of the transducer unless a drop-ended gynecological couch is available. Knees should be flexed; feet placed wide apart [Figure 17].{Figure 17}

Equipment and settings

Transvaginal transducer is necessary (C10-3 v, Philips Healthcare, Bothell, Washington, USA), with the system optimized for highest resolution possible at depth of pelvic organs. Resolution should be set as a preference over frame rate, with highest frequency setting selected for the transducer. Color PRF should be optimized for low-velocity flow (5–8 cm/s).

Standard protocol

The patient must be aware of the nature of the examination and consent obtained. The transducer should be covered with an appropriate probe cover and sterile lubricant. Empty bladder is preferable. In our experience, TVDUS is well tolerated with minimal discomfort. Use a very gentle scan technique to avoid compression or distortion of vascular anatomy.

A survey of the entire pelvis should be made in both longitudinal and coronal planes to assess anatomical orientation and pathology of the pelvic organs. Thereafter, coronal or coronal/oblique planes are most useful for evaluating the trunks and their tributaries. Angle the transducer into right and left lateral fornixes of the cervix to view IIVs and OVs. Anterior and posterior fornixes are useful for imaging anterior and posterior vaginal wall, urethra, and anal ring. Experience will deem preference for sequence of evaluation – several sonographers in our facility prefer to start with OVs, while others prefer IIVs due to their fixed location. Physical maneuvers (as below) are required in all vein territories to elicit reflux.

Bilateral ovarian veins

Start with the ovary in a coronal view, angle anterior, and the vein will be seen leading to the bottom of the image [Figure 18]a and [Figure 18]b. Due to their anterior position, it may be necessary for the patient to tilt hips upward to angle the transducer fully. The more distal portion of the OV typically lies less anterior between uterus and ovaries and also slightly anterior to IIVs [Figure 19]. Varices can be seen in this area and will likely communicate with the distal IIV through the uterine vein.{Figure 18}{Figure 19}

Bilateral internal iliac veins and their tributaries

These veins lie to the lateral sidewall of the pelvis [Figure 20]a and [Figure 20]b and more posterior than the OVs, the transducer should be angled to their position [Figure 21]. It may be necessary to withdraw the probe slightly to see the very distal tributaries.{Figure 20}{Figure 21}

Pelvic varices

Other areas within the pelvis should be evaluated for varices and reflux as below, with and without physical maneuvers. Use a coronal orientation for evaluation.

Arcuate veins of the uterus [Figure 22]. Note flow as this is a common path for drainage of contralateral reflux.Periuterine/uterine plexus, seen by angling the transducer slightly to the left and right of the uterus.Vaginal wall, seen by withdrawing the transducer slightly externally, and angle anterior toward the cervix.Periurethral [Figure 23]. Withdraw the transducer further toward the entrance of the vagina, and angle further anterior toward the pubic symphysis. Varicose veins in this location typically are responsible for the bladder symptoms.Perianal. With the transducer in the same position as above, angle posterior toward the anal canal. Varicosities will be seen distal to the anal ring, and hemorrhoids can be seen extending into the anal canal if they are present [Figure 24].{Figure 22}{Figure 23}{Figure 24}

Physical maneuvers

All veins seen tranvaginally should be evaluated with and without Valsalva and a Kegel squeeze.

Translabial ultrasound

Varices associated with pelvic venous reflux frequently are present in the vulva but likely will not protrude on clinical examination [as with [Figure 25]. Patient history is relevant, labial or vaginal wall varices noted during pregnancy or labial dragging/throbbing/itching can indicate their presence. Ultrasound assessment will show small-to-large caliber refluxing veins within the labia [Figure 26].{Figure 25}{Figure 26}

Patient position

Semi-recumbent, with head reclined to 45°. Knees should be flexed, and feet placed wide apart as with TVDUS.

Equipment and settings

A high-frequency linear transducer is preferable (we use a L18-5, Philips Healthcare, Bothell, Washington, USA) with system optimized for high-resolution superficial imaging. Resolution should be set as a preference over frame rate, with highest frequency setting selected for that transducer. Color PRF should be optimized for low-velocity flow (3–5 cm/s).

Standard protocol

It is preferable to cover the transducer with a cover and sterile lubricant. Evaluate both superficial and deep vulva [Figure 25]. Follow varices into the upper thigh or groin to view connection to lower extremity venous pattern. Other exit points, such as perineal, inguinal, clitoral, obturator, and superior/inferior gluteal points, should be evaluated.[7]

Physical maneuvers

The below maneuvers can be used to elicit reflux:

ValsalvaKegel squeezeA cough (usually the most successful way to elicit reflux in the vulvar region).

 Ultrasound Assessment for Pelvic Reflux in Males

Male pelvic ultrasound follows generally the same protocol as above, obviously without TVDUS. It is important to image as distal as possible transabdominally, evaluating for communication to the legs. Significant pressure may be required for distal imaging, and patient preparation is important.

Evaluate bilateral testis and epididymis for underlying pathology and symmetric volume. A unilateral reduction in testicular volume can be seen with significant and chronic varicocele. Assess for varicocele, which typically lies lateral to the testicle, but varices can be seen posterior or anterior within the scrotal sac and may extend into the inguinal canal, upper thigh, or groin area.

The testicular vein (TV) can be seen originating from the testes, passing through the inguinal canal [Figure 28] and draining upward into the LRV. It typically lies fairly superficial, at 1–2 cm in depth. If dilated, it likely can be seen in its entirety. Evaluate longitudinally and utilize CFD as with the OVs. Valsalva or Kegel maneuvers can be useful when imaging IIVs, TVs, and any varices seen. Assess upper thigh, perineal, suprapubic, and groin areas for communication to the legs. In our experience, TV/IIV communication appears to be less common in men than in women (OV/IIV), but there are often complex varicose communications between distal TVs in the inguinal canal and ipsilateral EIV or IIV.{Figure 27}{Figure 28}

 Postembolization Ultrasound

Repeat the technique described previously to assess for successful embolization, and information regarding veins treated during PVE should be at hand. Transabdominally, coils can be seen in the proximal to distal OVs [Figure 29]. If a “pseudo-nutcracker” was seen pre-PVE, this should be resolved [Figure 27]. For persistent ≥5:1 ratios, evaluate for variant anatomy of LRV and LOV (such as MA-LRV plus RA-LRV pathway, or LOV recanalization or collateralization). Carefully assess for coil migration, especially in EIVs as well as at insertions of ROV into IVC, LOV into LRV, and terminations of RIIV/LIIVs. Transvaginally, distal coils can be seen [Figure 30]. Evaluate all areas visualized coils with CFD and the described maneuvers. Any new reflux or unsuccessful treatment should be noted, and if significant, may need further treatment.{Figure 29}{Figure 30}

 Lower Extremity Venous Duplex Ultrasound: When to Suspect Pelvic Vein Reflux

When performing a duplex of the legs to evaluate for venous reflux, it is important to assess for signs of pelvic reflux in every patient, both men and women. Some key indications for pelvic reflux with communication to legs are:

Presence of varicose veins in the upper proximal thighs, which may or may not be seen on clinical examinationAtypical patterns of varicose veins which are not associated with truncal refluxRecurrent varicose veins.

Scan the proximal inner thigh up toward the groin, the posterior thigh toward the buttock crease and anal area, and lateral thigh toward the hip. It may be useful for the patient to bring their leg up on “tip-toe” for adequate visualization. Follow any varices cranially. Note that not all varicose veins of pelvic origin are seen in isolation, without truncal reflux.

Some typical presentations of varicose veins of pelvic origin are shown below, both in photographic and reflux scan diagram form. Upper thigh varices can vary in size, and even those that are ≤1 mm can be of clinical significance. Elongate the vein and utilize CFD. A cough will typically elicit reflux if it is pelvic.

Anterior-pelvic communication patterns

Anteromedical varicose veins lying superficial to the area of the adductor longus tendon [Figure 31] will not necessarily be obvious on clinical examination. A key indicator to their presence by ultrasound may be truncal reflux within the great saphenous vein (GSV) up to the proximal third of the thigh but not extending into proximal GSV or sapheno–femoral junction (SFJ). Proximal thigh varices may join on to any other trunk or none at all.{Figure 31}

Antero-lateral varices can be seen coursing toward the hip and can join with the AASV and/or its tributaries.

Posterior pelvic communication patterns

Posterior varices [Figure 32] are common with pelvic vein reflux. Typically, a small- vessel pattern will be observed, with ≤2 mm diameter varices and extensive thread veins. This pattern type can be one of the most symptomatic, with lower extremity aching and throbbing. The varices may also lead to the buttock crease, distal or proximal buttock, or lateral hip area.{Figure 32}

The varices may communicate directly onto the vein of Giacomini in the posterior thigh, and varices arising from Giacomini perforator veins may be present. Pain and aching in the area can be reported, especially when in an extended seated position.

Recurrent leg varicose veins

Pelvic vein reflux is a common finding with recurrent varicose veins, and patterns may be simple or complex. Simple patterns may present after successful ligation of the SFJ, sometimes with removal of the proximal third of the GSV, but without significant formation of neovascular tissue. Residual GSV in the mid-thigh is seen refluxing with communicating varices on the medial aspect of the thigh up to the pelvis [Figure 33]. Patients with more complex patterns might have gross neovascular recurrence at the SFJ and within the GSV strip track in addition to communicating varices to the pelvis. Varices may not be visible to the eye.{Figure 33}


With experience and high-quality imaging, ultrasound is a useful tool for the assessment of pelvic venous reflux. It is a dynamic test providing a true picture of pathophysiology and flow hemodynamics rather than relying on anatomy and vein diameter alone. It is less expensive and less invasive than other radiology methods such as CT, MR, or venography. Patient position can be modified to fit the indication and goal of the examination. Limitations include operator dependence, poor patient preparation, and low-quality imaging equipment. Recent technology advances including dynamic CFD 3D/4D [Figure 34] should increase diagnostic confidence, making TVDUS imaging more accessible to the less experienced operator.{Figure 34}

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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