RU2713800C1 - Method for differential diagnosis of primary and secondary varicose veins of small pelvis in males - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to an ultrasonic method for diagnosing varicose pelvic disease in males. In men with varicose veins of small pelvis, transabdominal examination of left renal vein, left common iliac vein is performed. Diameter of left renal vein and blood flow velocity in projection of aorto-mesenteric area are measured. Signs of left renal vein compression are: diameter of left renal vein in aorto-mesenteric area of 3.5 mm and less, velocity of blood flow in aortic mesenteric area of 100 cm/s and more. Blood flow diameter and velocity are measured in the left common iliac vein in the area of its intersection with the right common iliac artery. Symptoms of compression of left common iliac vein are: diameter of left common iliac vein in area of right common iliac artery intersection 5 mm and less, blood flow velocity within right common iliac artery 100 cm/s and more. If observing no signs of compression of left renal and left common iliac vein, primary varicose vein disease is diagnosed. If observing compression of left renal vein, or left common iliac vein, or a combination of their compression, secondary varicosity of pelvic vein in men is diagnosed.

EFFECT: method enables providing higher accuracy and information value of diagnosing varicosity of small pelvis in males, non-invasive differential diagnosis of primary and secondary varicose vein diseases, which significantly affects the therapeutic approach to patients, by evaluating the complex of the most significant indicators.

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Description

The invention relates to medicine, namely to methods for diagnosing varicose veins of the small pelvis in men.

Varicose veins of the pelvic vein (VVT) - a disease characterized by ectasia, varicose transformation and valvular failure of the venous plexuses of the pelvis and / or testicular veins with the development of pelvic venous congestion. In the international classification of diseases of the 10th revision (2015), varicose pelvic veins in gynecological practice have the code 186.2 and the name Pelvic varices, and in the urological - code N42.1 and the name Congestion and haemorrhage of prostate (Andrology and genital surgery - No. 2 Volume 17 - 2016 .-- C. 11-19).

The clinical diagnosis of VBT is difficult, due to the absence of specific symptoms of the disease. In this regard, the use of instrumental diagnostic methods for VBVT is relevant. VLBV in men is diagnosed according to the patient’s complaints, examination, ultrasound of the scrotum with vascular dopplerography, transrectal ultrasound (TRUS) of the prostate gland, magnetic resonance venography of the inferior vena cava and pelvic veins, phlebography of the testicular and iliac veins.

Given the fact that VBT may be a primary process (due to the primary development of valvular venous insufficiency) and secondary (due to arteriovenous conflicts leading to impaired outflow of blood through the left renal and / or left common iliac vein), in addition to the study of venous plexuses of the small the pelvis and testicular veins, it is necessary to conduct a study aimed at identifying possible causes of obstruction of the venous outflow: namely, the study of the left renal vein and the left iliac vein with c The goal is to diagnose arteriovenous conflicts (aorto-mesenteric compression, ileal compression - May-Turner syndrome), the detection of which will significantly affect the treatment tactics.

A known method of dopplerographic examination of the prostate gland (Clinical Guide to Ultrasound Diagnostics / Edited by V.V. Mitkov. T. 1. - M .: Vidar, 1996. - S. S. 273-297). The essence of the method is that using a transrectal ultrasound examination, the diameter of the veins of the paraprostatic venous plexus is measured with an estimate of the maximum speed of blood flow in the veins, while the diameter of the veins of the parastatic plexus is less than 4 mm, the blood flow velocity in them is more than 3 cm / s.

The disadvantage of this method is the lack of clear quantitative differential diagnostic criteria for impaired venous outflow (assessment of venous valve function and differential diagnosis of primary and secondary VBT), which makes it impossible to make an objective assessment of varicose veins of the pelvis in men.

A known method for the diagnosis of varicose veins of the pelvic organs (Kapto A.A. Endovascular surgery of the iliac veins with bilateral varicocele and varicose veins of the pelvic organs in men // Urological statements. - 2018. - T. 8. - No. 1. - C. 11-17. Doi: 10.17816 / uroved8111-17). The essence of the method is that with the help of transrectal ultrasound, the diameter of the veins of the paraprostatic venous plexus is measured, with the help of duplex angioscanning with a Valsalva test, the presence of reflux in the veins of the paraprostatic plexus is determined, and CT-phlebography and radiopaque phlebography are used to diagnose adeno-venous and venereal venous infections. VBT is verified with the expansion of the veins of the parastatic plexus of more than 5 mm and / or the presence of reflux of blood flow in them with a Valsalva test; aortomesenteric compression is verified when the aortomesenteric angle is less than 28 ° and the aortomesenteric distance is less than 10 mm; Iliac venous compression is verified with a lower lumbar lordosis angle of less than 134.33 ° and an iliac venous tunnel diameter of less than 4.18 mm.

The disadvantages of this method are the use of expensive, associated with significant radiation exposure methods (CT phlebography, radiopaque phleboraphy); in addition, radiopaque phlebography is an invasive method, which is associated with possible complications of the procedure.

There is a method of ultrasound diagnosis in determining varicose pelvic disease (Kurbonova NN, Sultanov DD, Umarova 3.3. The possibilities of ultrasound diagnostics for determining varicose pelvic disease // Bulletin of Avicenna. - 2017. - T. 19. - No. 3. - S. 382-386.). The essence of the method is that, using ultrasound duplex scanning, women evaluate transvaginally small pelvic veins, transabdominally inferior vena cava, iliac and renal veins, as well as veins of the lower extremities. VBT is verified with dilatation of the pelvic veins of more than 5 mm and / or the presence of blood flow reflux in them with a Valsalva test;

The disadvantages of the method are the absence of ultrasonic criteria for violation of the venous outflow along the left renal and left common iliac veins, which makes it impossible to make an objective assessment of varicose veins of the pelvic veins in men, as well as the lack of consideration of the structural features of the venous plexuses of the small pelvis in males.

The closest technical solution we have chosen is the methodology of ultrasound examination for varicose veins of the pelvis (Fomina E.E., Akhmetzyanov R.V., Tukhbatullin MG Methodology of ultrasound examination for varicose veins of the pelvic // Practical medicine. - 2016. - № 9. - P. 53-58.), The essence of which is a transvaginal examination of the diameter of the venous plexuses of the pelvis in women (cluster-like, uterine and parametric) with the determination of retrograde blood flow in them during the Valsalva test; transabdominal examination of the ovarian veins with determination of their diameter and determination of retrograde blood flow in them during the Valsalva test; transabdominal examination of the left renal vein for aorto-mesenteric compression; transabdominal examination of the inferior vena cava and iliac veins to determine patency.

The disadvantage of this method for the diagnosis of VBT in men is the lack of consideration of the structural features of the venous plexuses of the pelvis in males, the absence of ultrasound criteria for the diagnosis of ileal compression, the absence of criteria for the differential diagnosis of primary and secondary VBT. The disadvantages of the prototype are eliminated in the present method.

The task of the invention is to develop a method for the differential diagnosis of primary and secondary VBT in men.

The problem is solved in that in men of VBT they perform transabdominal ultrasound examination of the left renal vein and transabdominal ultrasound examination of the inferior vena cava and iliac veins, measure the diameter of the left renal vein and blood flow to the aorto-mesenteric and projection aorto-mesenteric regions, signs of compression of the left renal vein: the diameter of the left renal vein in the aorto-mesenteric region of 3.5 mm or less, the blood flow velocity in the aorto-mesenteric region of 100 cm / s or more, then measure they reveal the diameter and speed of blood flow in the left common iliac vein before it intersects with the right common iliac artery and in the area of intersection with the right common iliac artery, signs of compression of the left common iliac vein: diameter of the left common iliac vein in the area of intersection with the right common iliac artery is 5 mm or less, blood flow velocity in the area of intersection of the right common iliac artery of 100 cm / s or more, in the absence of signs of compression of the left renal and left common iliac veins, primary VBT is diagnosed, with In the presence of compression of the left renal vein, or of the left common iliac vein, or with a combination of their compression, secondary VVT is diagnosed.

The technical result of the application of the proposed method is to increase the accuracy of differential diagnosis of VBT in men with the definition of primary and secondary VBVT and the ability to choose the appropriate tactics of patient management.

The inventive method allows us to perform non-invasive differential diagnosis of primary and secondary VBT in men, which significantly affects the tactics of patient management. The first step in transrectal ultrasound is to measure the diameter of the veins of the paraprostatic venous plexus; measurement of blood flow velocity in the veins of the parastatic venous plexus; the determination of retrograde blood flow in the veins of the parastatic venous plexus during the test with straining, with the measurement of the duration of the retrograde blood flow, as well as with transabdominal ultrasound examination, the diameter of the testicular veins is measured, the determination of the retrograde blood flow in the testicular veins during the test with straining, with the measurement of the duration of the retrograde blood flow. An ultrasound examination of the paraprostatic venous plexus and testicular veins should be carried out in conjunction with an assessment of the left renal and left iliac veins, which allows not only to determine the degree of varicose veins, but also to identify possible etiological factors of disturbance of the venous outflow from the pelvic organs (aorto-mesenteric compression , iliac compression). In the case of detecting signs of varicose veins of the pelvis in the absence of signs of compression of the left renal and left common iliac veins, primary VVT is diagnosed. In the case of signs of varicose veins of the small pelvis against the background of compression of the left renal vein, or the left common iliac vein, or a combination of their compression, a secondary VVT is diagnosed.

In the case of verification of primary VBT, the method of choice in the management of patients is conservative treatment, or operations that interrupt the blood flow through the ovarian veins and veins of the parastatic venous plexus - sclerobliteration / resection of the testicular vein / embolization of the testicular vein and sclerobliteration / embolization of paraprostatic veins. In the case of verification of secondary VHF, the operations of choice will be: when stenosis of the left renal vein is detected - stenting of the LPV, or its transposition, if stenosis of the left common iliac vein is detected - balloon angioplasty and stenting of the left common iliac vein. In the event that interruption of blood flow through the left testicular vein and paraprostatic veins without taking into account the presence of compression of the left renal vein in the aorto-mesenteric region, it is possible to develop irreversible damage to the left kidney due to a significant deterioration in venous outflow with the development of phlebohypertension (Hartung O. Compression syndrome the left renal vein in aortomesenteric forceps (nutcracker syndrome). Phlebolymphology. 2010; 36; 10-15). If you do not take into account the violation of the outflow along the left common iliac vein and embolize paraprostatic veins, then this will inevitably lead to a relapse of the disease.

The medical literature has enough data on the effect of compression of the left renal vein on the development of varicocele, however, only a few experts take into account the effect of compression of the left renal vein and left common iliac vein on the development of impaired venous outflow from the pelvis. There are sufficient quantitative parameters to allow ultrasound evaluation of compression of the left renal vein in the aorto-mesenteric region, however, in the medical literature there are no quantitative ultrasonic parameters to verify compression of the left common iliac vein. In retrospect, we evaluated data from 41 patients with VBT who underwent ultrasound examination of the iliac veins and subsequent iliac vein venography with phlebotonometry. We found that in patients whose compression of the iliac veins with phlebotonometry verified compression of the left common iliac vein, according to ultrasound, the diameter of the left common iliac vein in the area of intersection of the right common iliac artery was 5 cm or less, the blood flow velocity in the left common iliac vein in the area of intersection with the right common iliac artery was 100 cm / s or more, which indicates secondary VVT. Thus, our proposed method is a mandatory diagnostic algorithm that should be performed by all men with VVT in order to timely differential diagnosis of primary and secondary VVT and to prevent erroneous treatment methods that can lead not only to relapse of the disease, but also the development of formidable complications.

A detailed description of the method and examples of its clinical application

The method is as follows.

Preparing the patient for the study consists in the need to perform the study on an empty stomach, as well as in the preliminary emptying of the intestines and bladder.

The studies were performed on a PHILIPS EPIQ 5 ultrasound device (Japan) using a convex multi-frequency sensor with a frequency range from 1-5 MHz and a transrectal multi-frequency sensor with a frequency range from 4-10 MHz.

The first stage is the study of the veins of the pelvis. The patient's position is "lying on the left side", the legs are bent at the knee joints, with the knees brought to the body. A small amount of gel for ultrasound testing is applied to the transrectal sensor, an latex condom is put on to the sensor for ultrasound, and a small amount of ultrasonic gel is also applied to its surface. The sensor is inserted into the ampoule of the rectum, then the scanning surface of the sensor is sequentially rejected to the right and left, the state of the parastatic venous plexus is assessed on the right and left. In the B-mode, the diameter of the veins of the paraprostatic venous plexus is measured at the site of the greatest expansion of the veins; in the spectral Doppler mode, blood flow velocity is measured in the veins of the paraprostatic venous plexus and the presence of retrograde blood flow in the veins of the parastatic venous plexus is measured during straining, indicating valve failure, and the duration of the retrograde blood flow is measured. Varicose pelvic disease is diagnosed with dilatation of the paraprostatic plexus veins of more than 4 mm, a decrease in blood flow velocity in the veins of the parastatic plexus below 3 cm / s, and the presence of retrograde blood flow in the veins of the parastatic plexus for more than 0.5 seconds.

Next, the patient is located in the supine position, a convex sensor through the anterior abdominal diameter is used to measure the diameter of the right and left testicular, retrograde blood flow is determined during the test with straining, indicating valve failure, with a measurement of its duration. Varicose veins of the testicular veins are diagnosed with ectasia of veins more than 5 mm with the presence of retrograde blood flow during the test with straining for more than 0.5 seconds.

If at the first stage there are signs of varicose veins of the small pelvis, the patients undergo the second stage transabdominal examination of the left renal and left iliac veins with the aim of differential diagnosis of primary and secondary VBMT.

In the position of the patient "lying on his back", convex sensor through the front abdominal wall achieve the best visualization of the vascular leg of the left kidney. In the B-mode, the diameter of the left renal vein is measured, in the spectral Doppler mode, the blood flow velocity to the aorto-mesenteric and projection of the aorto-mesenteric region is measured. Signs of compression of the left renal vein: diameter of the left renal vein in the aorto-mesenteric region 3.5 mm or less, blood flow in the aorto-mesenteric region 100 cm / s or more.

In the position of the patient "lying on his back", convex sensor through the front abdominal wall achieve the best visualization of the left common iliac vein. In B-mode, the diameter of the left common iliac artery is measured until it intersects with the right common iliac artery and in the area of the intersection of the right common iliac artery. In the spectral Doppler mode, blood flow velocity is measured in the left common iliac vein before it intersects with the right common iliac artery and in the area of intersection with the right common iliac artery. Signs of compression of the left common iliac vein: the diameter of the left common iliac vein at the intersection of the right common iliac artery 5 mm or less, the blood flow velocity at the intersection of the right common iliac artery 100 cm / s or more. In the case of detecting signs of varicose veins of the small pelvis in the absence of signs of compression of the left renal and left common iliac veins, primary varicose vein disease of the pelvis is diagnosed. In the case of signs of varicose veins of the pelvis against the background of compression of the left renal vein, or the left common iliac vein, or a combination of their compression, a secondary varicose vein disease is diagnosed.

The proposed method for the diagnosis of varicose pelvic disease in men allows for non-invasive differential diagnosis of primary and secondary varicose pelvic disease, which largely determines the management tactics of patients.

Example 1

Patient N-ko, 44 years old, turned to a urologist with complaints of discomfort in the perineum, difficulty urinating, intensified after intercourse over the past 2 years. After clinical and laboratory diagnosis, the diagnosis was made: abacterial prostatitis / chronic pelvic pain syndrome, the patient was sent for ultrasound examination of the pelvic veins, which revealed an expansion of paraprostatic veins on the right to 5.2 mm, on the left to 7.4 mm, a decrease in blood flow velocity in the veins paraprostatic plexus on the right up to 2.9 cm / s, on the left up to 2.4 cm / s, when conducting a test with straining recorded retrograde blood flow in the veins of the parastatic plexus on the right lasting 0.77 s, on the left 2.9 s.

A transabdominal ultrasound examination of the testicular veins was performed. The diameter of the right testicular vein was 3 mm, the left testicular vein was 5 mm, and a retrograde blood flow in the left testicular vein lasting 2 seconds was determined during a stiff test. A transabdominal examination of the left renal and left iliac veins was performed. The diameter of the left renal vein and blood flow to the aorto-mesenteric and projection of the aorto-mesenteric region, the diameter and speed of blood flow in the left common iliac vein to the intersection of the right common iliac artery and in the area of the intersection of the right common iliac artery were measured. There was a narrowing of the left renal vein in the aorto-mesenteric region to 3.5 mm, the blood flow velocity in the narrowing region was 100 cm / s. The diameter of the left common iliac vein in the area of intersection of the right common iliac artery was 6.5 mm, the blood flow velocity was 64 cm / s. The study allowed us to interpret the data as signs of secondary varicose veins of the pelvis against the background of aorto-mesenteric compression of the left renal vein.

Example 2

Patient Chev, 30 years old, turned to a urologist with complaints of pain in the left half of the scrotum, lower abdomen for 2 years. A history of Marmara surgery on the left. After clinical and laboratory diagnostics, the diagnosis was made: abacterial prostatitis / chronic pelvic pain syndrome, the patient was sent for ultrasound examination of the pelvic veins, which revealed expansion of paraprostatic veins on the right to 4.9 mm, on the left to 7.8 mm, decrease in blood flow in the veins paraprostatic plexus on the right up to 2.9 cm / s, on the left up to 2.4 cm / s, when conducting a test with straining, retrograde blood flow was recorded in the veins of the paraprostatic plexus on the right for 0.9 s, 2.8 s on the left.

A transabdominal ultrasound examination of the testicular veins was performed. The diameter of the right testicular vein was 3 mm, the left testicular vein was 3.2 mm; no retrograde blood flow was detected in the testicular veins when the test was performed with straining. A transabdominal examination of the left renal and left iliac veins was performed. The diameter of the left renal vein and blood flow to the aorto-mesenteric and projection of the aorto-mesenteric region, the diameter and speed of blood flow in the left common iliac vein to the intersection of the right common iliac artery and in the area of the intersection of the right common iliac artery were measured.

There was a narrowing of the left common iliac vein in the area of intersection of the right common iliac artery to 5, the blood flow velocity in the narrowing area was 100 cm / s; The diameter of the left renal vein in the aorto-mesenteric region was 5.2 mm, and the blood flow velocity was 45 cm / s. The study allowed us to interpret the obtained data as signs of secondary varicose veins of the pelvis against the background of iliac compression of the left common iliac vein.

Example 3

Patient E-ko, 47, turned to a urologist with complaints of discomfort in the perineum, difficulty urinating, scrotal pain. After clinical and laboratory diagnostics, the diagnosis was made: abacterial prostatitis / chronic pelvic pain syndrome, the patient was sent for ultrasound examination of the pelvic veins, which revealed expansion of paraprostatic veins on the right to 5.9 mm, on the left to 9.4 mm, decrease in blood flow in the veins paraprostatic plexus on the right up to 2.2 cm / s, on the left up to 2.1 cm / s, when conducting a test with straining recorded retrograde blood flow in the veins of the paraprostatic plexus on the right for 1.6 s, 3.2 s on the left.

A transabdominal ultrasound examination of the testicular veins was performed. The diameter of the right testicular vein was 3 mm, the left testicular vein was 5.8 mm, and a retrograde blood flow in the left testicular vein lasting 2 seconds was determined during a stiff test. A transabdominal examination of the left renal and left iliac veins was performed. The diameter of the left renal vein and blood flow to the aorto-mesenteric and projection of the aorto-mesenteric region, the diameter and speed of blood flow in the left common iliac vein to the intersection of the right common iliac artery and in the area of the intersection of the right common iliac artery were measured. There was a narrowing of the left renal vein in the aorto-mesenteric region to 3.3 mm, the blood flow velocity in the narrowing region was PO cm / s; There was a narrowing of the left common iliac vein at the intersection of the right common iliac artery to 4.8, the blood flow velocity in the narrowing area was 118 cm / s; The study made it possible to interpret the obtained data as signs of secondary varicose veins of the pelvis against the background of a combination of aorto-mesenteric compression of the left renal vein and iliac compression of the left common iliac vein.

Example 4

Patient Ms, 28 years old, turned to a urologist with complaints of discomfort in the perineum for 8 months. After clinical and laboratory diagnostics, the diagnosis was made: abacterial prostatitis / chronic pelvic pain syndrome, the patient was sent for ultrasound examination of the pelvic veins, which revealed an expansion of paraprostatic veins on the right to 6.5 mm, a decrease in blood flow velocity in the veins of the paraprostatic plexus on the right to 2.3 cm / s, when conducting a test with straining, retrograde blood flow was recorded in the veins of the paraprostatic plexus on the right for 2.8 s; the veins of the paraprostatic plexus on the left are not dilated, the blood flow velocity is not impaired.

A transabdominal ultrasound examination of the testicular veins was performed. The diameter of the right testicular vein was 2.8 mm, the left testicular vein 3.2 mm, when conducting a test with straining retrograde blood flow in the testicular veins was not detected. A transabdominal examination of the left renal and left iliac veins was performed. The diameter of the left renal vein and the blood flow to the aorto-mesenteric and projection of the aorto-mesenteric region, the diameter and speed of blood flow in the left common iliac vein to the intersection of the right common iliac artery and in the area of the intersection of the right common iliac artery were measured.

The diameter of the left renal vein in the aorto-mesenteric region was 5.8 mm, and the blood flow velocity was 41 cm / s. The diameter of the left common iliac vein in the area of intersection of the right common iliac artery was 6.8 mm, the blood flow velocity was 50 cm / s. The study allowed us to interpret the data as signs of primary varicose veins of the small pelvis.

The effectiveness of our method was confirmed in a study of 38 patients who contacted a urologist complaining of pain in the lower abdomen, scrotal pain, and urination impairment. Based on the ultrasound angioscanning of the pelvic veins, aorto-mesenteric region, iliac veins according to the claimed method, signs of primary varicose veins of the pelvic veins were revealed in 18 patients, and signs of secondary varicose veins of the pelvis in 2 patients

After that, all patients underwent selective venography of the pelvic veins, renal and iliac veins, the results of which confirmed the presence of primary varicose veins of the pelvic veins in 18 patients, the presence of secondary varicose veins of the pelvic veins in 2 patients.

To assess the correctness of the negative results, 18 patients who did not show signs of varicose veins of the pelvis, according to a comprehensive ultrasound scan, also performed selective venography of the pelvic veins, renal and iliac veins, the data of which confirmed the absence of varicose veins, aorto-mesenteric and iliac compression.

The proposed method for differential diagnosis of primary and secondary varicose veins of the small pelvis in men is informative, simple, highly accurate and reliable when studying the venous system of the small pelvis in men.

The application of the proposed method will allow to make a correct diagnosis in time, prescribe an adequate treatment and evaluate its effectiveness.

The inventive method allows for non-invasive differential diagnosis of primary and secondary varicose veins of the pelvic veins, which significantly affects the tactics of patient management.

The invention is industrially applicable, as it can be used in healthcare, in medical institutions provided with appropriate ultrasonic equipment.

Claims (1)

A method for differential diagnosis of primary and secondary varicose veins of the pelvic veins in men, including transabdominal examination of the left renal vein, left common iliac vein, characterized in that the diameter of the left renal vein and blood flow in the projection of the aorto-mesenteric region are measured, with signs of compression of the left the renal vein is detected if: the diameter of the left renal vein in the aorto-mesenteric region is 3.5 mm or less, the blood flow velocity in the aorto-mesenteric region is 100 cm / s or more, then measure the diameter and speed of blood flow in the left common iliac vein in the region of its intersection with the right common iliac artery, and signs of compression of the left common iliac vein are detected if: the diameter of the left common iliac vein in the area of the intersection of the right common iliac artery is 5 mm or less; the area of intersection of the right common iliac artery of 100 cm / s or more; in the absence of signs of compression of the left renal and left common iliac veins, primary varicose veins of the pelvic veins are diagnosed, in the presence of compression of the left renal veins, left common iliac veins, or a combination of their compression, secondary varicose veins of the pelvic veins in men are diagnosed.