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Vulvar Varicosities in an Adolescent Girl with Morbid Obesity: a Case Report

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Vulvar Varicosities in an Adolescent Girl with Morbid Obesity: a Case Report children Case Report Vulvar Varicosities in an Adolescent Girl with Morbid Obesity: A Case Report Aikaterini Giannouli 1, Vasiliki Rengina Tsinopoulou 2 , Artemis Tsitsika 3, Efthimios Deligeoroglou 4 and Flora Bacopoulou 1,* 1 Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece; [email protected] 2 Unit of Paediatric Endocrinology and Metabolism, 2nd Department of Paediatrics, School of Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54621 Thessaloniki, Greece; [email protected] 3 Adolescent Health Unit, 2nd Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, “P. & A. Kyriakou” Children’s Hospital, 11527 Athens, Greece; [email protected] 4 Department of Pediatric & Adolescent Gynecology, Mitera Children’s Hospital, 15123 Athens, Greece; [email protected] * Correspondence: [email protected]; Tel.: +30-6973208208 Abstract: Vulvar varicosities in nonpregnant females, either isolated or as a part of the pelvic congestion syndrome, are rare. We present a case of an adolescent girl with morbid obesity with bilateral bluish protrusions on the labia minora, as an incidental finding, that coincided with her excessive weight gain. The adolescent underwent thorough clinical examination, doppler ultrasound, contrast venography and varicography, and magnetic resonance angiography to rule out alternative diagnoses. Imaging results confirmed the presence of large venous lakes. Venous drainage to the internal iliac vein and connections with the long saphenous vein were delineated. Incompetence, Citation: Giannouli, A.; Tsinopoulou, dilatation, or reflux of ovarian or internal iliac veins, or their main tributaries, were not noted. V.R.; Tsitsika, A.; Deligeoroglou, E.; Bacopoulou, F. Vulvar Varicosities in Since the adolescent was asymptomatic and other pathologies, such as vascular malformations an Adolescent Girl with Morbid or hemangiomas were excluded, she was managed conservatively with counseling about lifestyle Obesity: A Case Report. Children modification and weight reduction. This is only the third reported case of vulvar venous varicosities 2021, 8, 202. https://doi.org/ in adolescents. Female sex, along with obesity, are known risk factors for varicose vein formation; 10.3390/children8030202 however, the pathogenesis is not fully understood. Additional research is needed to elucidate the role of excess adipose tissue in the pathophysiology of vulvar varicose veins and to optimize diagnostic Academic Editor: Sari Acra workup and management in adolescence. Received: 31 December 2020 Keywords: adolescence; vulvar; varicosities; vulva; obesity; varicose veins; pelvic venous disorder; Accepted: 4 March 2021 pelvic congestion syndrome Published: 7 March 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in 1. Introduction published maps and institutional affil- iations. Vascular varicosities, i.e., dilated venous channels in the vulvar area, are rare and almost exclusively affect women during pregnancy. Almost 4–22% of pregnant women present with vulvar varicosities. The majority of cases disappear either immediately after parturition or during puerperium, and only 4–8% persist or worsen with time [1–3]. The prevalence of the disorder in nonpregnant women is not estimated, because only a Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. handful of cases are published in literature [4,5]. Vulvar varicosities are included in pelvic This article is an open access article venous syndromes (PVS). PVS are disorders of the pelvic venous circulation and, in 24–34% distributed under the terms and of the cases, coincide with visible varicosities on the vulva, thigh, or gluteal area [2]. These conditions of the Creative Commons disorders are developed by increased vascular pressure due to obstruction, compression, Attribution (CC BY) license (https:// valvular incompetence, or both [1]. Obesity has a divergent effect on PVS; increasing creativecommons.org/licenses/by/ weight is associated with a higher prevalence of leg varicosities and lower prevalence of 4.0/). proximal vein flow disorders [6–8]. Children 2021, 8, 202. https://doi.org/10.3390/children8030202 https://www.mdpi.com/journal/children Children 2021, 8, 202 2 of 6 Children 2021, 8, 202 2 of 6 ditions of the Creative Commons At- weight is associated with a higher prevalence of leg varicosities and lower prevalence of tribution (CC BY) license (http://crea- proximal vein flow disorders [6–8]. tivecommons.org/licenses/by/4.0/). Most females with visible vulvar varices do not report any symptoms, especially dur- ing Mostpregnancy. females Palpable with visible mass vulvaron the varicesexternal do genitalia, not report vaginal any symptoms, discomfort, especially swelling, duringheaviness, pregnancy. and pain Palpable are rare mass manifestations. on the external These genitalia, symptoms vaginal usually discomfort, deteriorate swelling, at the heaviness,end of the andday painafter arestanding rare manifestations. up, exercise, orThese coitus. symptoms Due to the usually paucity deteriorate of symptoms at theand end of the day after standing up, exercise, or coitus. Due to the paucity of symptoms and the embarrassment to report changes in the external genitalia, most cases of vulvar varices the embarrassment to report changes in the external genitalia, most cases of vulvar varices in pregnant women are diagnosed at term or even during labor. in pregnant women are diagnosed at term or even during labor. 2.2. Case Case Presentation Presentation AA 16-year-old 16-year-old Caucasian Caucasian girl girl was was referred referred to to the the Center Center for for Adolescent Adolescent Medicine Medicine and and UNESCOUNESCO Chair Chair on on Adolescent Adolescent Health Health Care Care of of the the First First Department Department of Pediatrics,of Pediatrics, School School of Medicine,of Medicine, National National and and Kapodistrian Kapodistrian University University of Athens, of Athens, at the at Aghia the Aghia Sophia Sophia Children’s Chil- Hospital.dren’s Hospital. Her main Her concerns main concerns were oligomenorrhea were oligomenorrhea and a mass and over a mass her external over her genitalia external observedgenitalia byobserved the referring by the gynecologist. referring gynecologist. TheThe adolescent adolescent presented presented with with a a history history of of excessive excessive weight weight gain gain (over (over 30 30 kg kg during during thethe past past 2 years),2 years), recently recently diagnosed diagnosed Hashimoto’s Hashimoto’s thyroiditis, thyroiditis, and oligomenorrhea.and oligomenorrhea. She had She ahad family a family history history of type of 2type diabetes 2 diabetes mellitus. mellitus. She had She menarchehad menarche at 12 at years 12 years of age, of andage, sheand reportedshe reported normal normal menstrual menstrual cycles cycles during during the th firste first two two gynecological gynecological years. years. In In the the last last twotwo years, years, menses menses were were irregular irregular with with secondary secondary amenorrhea amenorrhea for for 4 4 months. months. She She denied denied recentrecent trauma trauma at at the the vulvar vulvar or or perineal perineal area, area, and and her her mother mother reported reported that that no no vulvar vulvar mass mass hadhad been been observed observed in in her her past past pediatric pediatric health health visits. visits. The The adolescent adolescent did did not not complain complain of of heaviness,heaviness, discomfort, discomfort, or or regional regional pain pain at at any any position position or or following following exercise exercise or or prolonged prolonged standing.standing. SheShe diddid notnot reportreport sexarche;sexarche; however,however, aa urine urine pregnancy pregnancy test test was was performed, performed, andand pregnancy pregnancy was was ruled ruled out. out. Initially,Initially, the the girlgirl waswas examined in in the the lithotomy lithotomy position position and and then then in inthe the upright upright po- position.sition. In Inthe the lithotomy lithotomy position, position, bilateral bilateral bluish bluish protrusions protrusions were were observed observed on onlabia labia mi- minoranora (Figure (Figure 1).1 ).On On the the right right side, side, the thesize size of the of themass mass was was3 cm 3 × cm 1.5 cm,× 1.5 and cm, on and the left, on thethere left, was there a smaller was a mass smaller of 1.5 mass cm of × 1 1.5 cm. cm Both× 1 masses cm. Both were masses soft, nontender, were soft, and nontender, variable andin size variable with palpation. in size with With palpation. the Valsalva With maneuver the Valsalva and maneuver while standing, and while the masses standing, en- thelarged, masses but enlarged, they reduced but they in size reduced with pressure. in size with The pressure. perineum, The the perineum, inguinal thearea, inguinal the glu- area,teal region, the gluteal and the region, lower and limbs the were lower free limbs of varices. were free The of external varices. genitalia The external were genitaliaotherwise werenormal. otherwise normal. Figure 1. Vulvar varicosities observed in the lithotomy position. Figure 1. Vulvar varicosities observed in the lithotomy position. The adolescent had morbid obesity, with a
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