What is it about?

We had previously published a paper showing that 3% of males with leg varicose veins have a significant contribution of venous relfux from pelvic varicose veins. All doctors are taught that in men, varicose veins of the testicular vein can cause varicose veins around the testicle, a condition called "varicocele". However, no one had previously pointed out that and venous reflux in these veins, and also venous reflux in other pelvic veins called the internal iliac veins, can also lead to leg varicose veins. We had previously published research in women showing that 20% (one in five) women with leg varicose veins have a major contribution from pelvic varicose veins. We have shown that failure to treat these pelvic varicose veins is a major cause of recurrent varicose veins in women. As such, we have suggested that no woman should have their leg varicose veins treated if they have pelvic vein reflux, without considering treating the pelvic veins first. Having seen a series of men with complex recurrent varicose veins, arising from pelvic varicose veins, we published our original study to highlight this similar problem in men. In an invited commentary, Dr Mel Rosenblatt gave his views on our paper. In it he suggested that perhaps reflux in the testicular vein caused varicocele but not leg varicose veins, and so it would be sensible to treat the leg varicose veins first and only consider pelvic varicose vein treatments if the leg varicose veins recurred. In this publication, we pointed out that this would result in some of these patients having a higher risk of recurrence after leg vein surgery. This would mean that they underwent leg varicose vein surgery and, in the future, with then need pelvic vein treatment and even more leg varicose vein surgery. We illustrated this with a case where a clear communication can be seen from the testicular vein causing leg varicose veins.

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Why is it important?

The importance of this research is to continue developing strategies to reduce the risk of varicose veins recurring again after surgery. At the Whiteley Clinics, we have developed the Whiteley Protocol. This is a research-based approach to the diagnosis and treatment of varicose veins and other venous diseases. By following a set pathway of investigations, and then basing our treatments on the results of these tests, we have managed to reduce the risk of recurrence to the lowest level possible. At the current time the chance of recurrence of variocse veins in our patients is the same as the risk of developing varicose veins in someone who has never had the problem previously. The only way that we have acheived this is by continually looking at why patients may get recurrent varicose veins after treatment and addressing each finding in turn. Our early work was all based upon stopping the same vein coming back again, showing things like stripping can cause the same vein to regrow. Having successfully developing strategies to stop a treated vein from ever coming back, we are now looking at other causes of recurrence. One of the major other causes is missing a cause of reflux at the original operation. Many surgeons follow the thought processes that Dr Mel Rosenblatt outlines in his commentary. They advocate treating the most obvious problem first (the leg varicose veins) and only coming back to re-treat the patient if veins recur. We are not saying that this is wrong, but we feel that if doctors wish to do this, they should warn the patients before surgery. In our opinion, patients should be given the very best treatment in the first place to give them the lowest chance of recurrence in the future. By leaving some incompetent veins untouched in the first procedure, we feel that the risk of recurrence is clearly going to be higher (as illustrated by the case we have presented) and thus the patient should be informed if this sort of strategy is going to be followed. After all, they are going to have to go thorugh further operations that might have been avoided, and also someone is going to have to fund the additional procedures. In our opinion, and embedded in the Whiteley Protocol, it is better to treat all veins that are showing significant reflux in the primary treatment, in order to give patients the very best chance of cure and the lowest chance of recurrence in the future. In this way, we hope to stop both professionals and the public from still believing that "varicose veins always come back again" after treatment!


Varicose veins are primarily associated with valves failing in leg veins, rendering the vein as incompetent, and allowing venous blood to reflux the wrong way through the veins. In the past, doctors treating varicose veins have concentrated on the two main truncal veins in the legs, the great saphenous vein and the small saphenous vein. Since the advent of endovenous surgery, it has become clear that there are a great many other veins that can cause varicose veins. These include the anterior accessory saphenous vein, incompetent perforating veins and incompetent pelvic veins. Leg veins are relatively easy to investigate and treat because they are near the surface and so venous duplex ultrasound can be used to see any incompetence within the veins. However, pelvic veins are more difficult to see with venous duplex ultrasonography because the veins are deeper and they are often covered by bowel which can contain gas. Over the last decade and a half, research at the Whiteley Clinics has shown how to identify venous reflux in the females using the transvaginal venous duplex ultrasound scan (TVUS) using the Holdstock protocol. This has been incorporated into the Whiteley Protocol. we have previously published that this test appears to be the gold standard investigation for pelvic venous relfux in females. However, for obvious anatomical reasons, male pelvic veins are much more difficult to investigate. Furthermore, because so many men have testicular vein reflux picked up at a young age due to testicular varicocele being obvious on clinical examination and often treated in youth, the correlation between pelvic venous reflux, pelvic congestion syndrome and leg varicose veins in males is much more difficult to investigate. In traditional anatomical books, doctors are taught that when the testicle descends in the foetus from the kidney area to the scrotum, it brings the testicular vein with it. By traditional teaching, this long vein does not connect with any other veins lower in the pelvis or leg. Our research has shown that this is not the case and the testicular vein can link with leg varicose veins. Indeed it can actually cause leg varicose veins if the testicular vein and linking vein are both incompetent. This has been illustrated in the case presented in this publication. The venous system is more complex than traditional textbooks suggest and shows why we continue to research and develop our diagnostic and treatment algorithms that make up the Whiteley Protocol.

Professor Mark S Whiteley
The Whiteley Clinic

Read the Original

This page is a summary of: Response to “Commentary on pelvic venous reflux in males with varicose veins and recurrent varicose veins”, Phlebology The Journal of Venous Disease, November 2018, SAGE Publications,
DOI: 10.1177/0268355518811033.
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