Direct transvaginal ultrasound-guided sclerotherapy for pelvic venous disease

To report feasibility, safety, and clinical outcomes of direct transvaginal ultrasound (TVUS)-guided foam sclerotherapy for isolated periuterine/pericervical varices or residual venous reservoirs after prior embolization.

Prospective single-center observational cohort including consecutive women (January 2023-October 2025) meeting predefined inclusion and exclusion criteria. Procedures were performed under general anesthesia using ultrasound-guided transvaginal venous puncture with fluoroscopic confirmation. Low-nitrogen 3% polidocanol foam was injected directly into the targeted periuterine and pericervical venous plexuses until complete filling of the treated reservoirs was achieved. Primary end points were technical success and changes in the Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ) score at 1 month and 1 year. Normality was evaluated with the Shapiro-Wilk test, repeated-measures analysis of variance with Mauchly's test for sphericity, and Tukey's honestly significant difference for pairwise comparisons (α = 0.05). Institutional review board approval was obtained, and informed consent was required.

Twenty-three patients (mean age, 40.5 years) underwent treatment; 74% had a history of prior gonadal vein embolization and presented with persistent symptoms at inclusion, whereas 26% had no prior embolization and presented with isolated periuterine or pericervical varices without axial reflux. Technical success was 100%. The mean procedural time was 36.0 ± 12.5 minutes, and the mean fluoroscopy time was approximately 1 minute. The mean sclerosant volume was 18.5 ± 5.3 mL. Radiation exposure remained low, with a mean dose-area product of 1.945 ± 0.347 Gy cm² and a mean absorbed dose of 72.0 ± 3.1 mGy. All patients were discharged the same day and resumed normal activities the following day. Minor vaginal bleeding occurred in 82% the day after treatment; no menstrual disturbances were reported. TVUS follow-up showed complete closure of the treated periuterine and pericervical venous plexuses, without evidence of recanalization in any patient at follow-up. The PVCSS improved from 12.91 at baseline to 7.87 (1 month) and 7.96 (1 year); the PVVQ score improved from 75.97 to 46.12 and 50.32, respectively. Overall improvement was significant (P < .001). Tukey's honestly significant difference confirmed decreases from baseline to 1 month and 1 year for both scales (PVCSS, P < .001; PVVQ, P < .003); the 1-month vs 1-year differences were not significant (PVCSS, P = .987; PVVQ, P = .094).

Direct TVUS-guided 3% polidocanol foam sclerotherapy achieved high technical success, as well as significant and durable symptom improvement at 1 year in this small, highly selected cohort, with no major complications or recanalization. The technique offers a minimally invasive, targeted option for periuterine and pericervical venous reservoirs, particularly in cases not amenable to conventional endovascular access.