Recognizing Pelvic Origin in Varicose Veins: A Case Study Highlighting the Importance of Comprehensive Venous Assessment

Patient: Lisa S.
Age: 43 years
Date of Study: September 5, 2025

Lisa presented with prominent varicose veins originating from her right gluteal fold, coursing down the
posterior thigh into the popliteal fossa. She reported leg heaviness but denied pelvic pain or discomfort.
Despite the absence of overt pelvic symptoms, her pattern of varicosities was clinically suspicious for
pelvic origin venous disease.

Duplex Ultrasound Findings

Right Lower Extremity:
– Segmental reflux noted in the right great saphenous vein (GSV).
– Large varicosities originating from the right gluteal fold, extending posterolaterally down the thigh into
the calf.
– These varicosities communicated with a small saphenous vein with prolonged reflux (11,000 ms).
Left Lower Extremity:
– Reflux from the saphenofemoral junction to the proximal calf within the left GSV.
– Multiple varicosities (4–7 mm) feeding from the medial thigh to the posterior and medial calf.
– Connections to left posterior calf gastrocnemius perforator (2.5 mm), medial thigh femoral perforator
(3.1 mm), and distal calf posterior tibial perforator (2.0 mm).
– Left AASV not visualized; PASV and SSV competent.
– Left lateral tributaries (1.8 mm) appeared to originate from a higher source, feeding into
posterior-lateral thigh and buttock varicosities.
– Patient also reported vulvar varicosities.

Recommendations
– Consider Iliac Vein Duplex if clinically indicated, given findings of pelvic-origin varicosities, multiple
perforators and large pudendal tributaries.
– Consider right GSV radiofrequency ablation (RFA) with microphlebectomy.
– Consider left GSV RFA with microphlebectomy if indicated

Teaching Points
This case underscores a critical diagnostic principle: The absence of pelvic symptoms does not
exclude a pelvic source of reflux.

Key learning objectives for advanced providers:

1. Pattern recognition: Varicosities from the gluteal fold, posterior thigh, and vulvar region suggest
pelvic venous hypertension or iliac obstruction.
2. Clinical dialogue: Patients should be informed of possible pelvic origin, even when symptoms are
minimal.
3. Avoiding incomplete treatment: Treating only the GSV without addressing pelvic reflux can lead to
recurrence.
4. Documentation: Clearly document that pelvic contribution was discussed and considered.

Reflection Assignment:
Review this case carefully and consider:
– What clues suggested a pelvic source?
– How could the initial consultation better frame this discussion?
– How will you apply this reasoning to future cases?