Response to “Pelvic venous reflux in male: Varicocele?”

Dear Editor,

We thank Ozturk and Yetkin ¹ for their very interesting comments on our paper ² and recognise the excellent contribution Yetkin has made in the observation of dilating diseases in blood vessels, co-existing in arterial and venous systems.

However with regard their comments, we would answer as follows.

Their assertion that the conclusion of our paper is that ‘pelvic venous reflux (PVR) can contribute to venous reflux development in leg varicose veins in males’ is not correct. We did not conclude anything about the development of varicose veins merely that in the presented eight cases, pelvic venous reflux was directly linked to the reflux causing varicose veins in these men. ² As we have already shown that untreated pelvic vein reflux is a major contributing factor to recurrent varicose veins in females, ³ our conclusion was a suggestion that male patients showing pelvic venous reflux that directly refluxes into leg varicose veins should have this identified and probably treated for the complete treatment of their varicose veins. ²

Ozturk and Yetkin go on to discuss the difference between the pelvic venous reflux being causative in the development of leg varicose veins against the chance that the two may just coexist. However, we did not discuss this at all in our paper. We merely showed that in this series of patients, we could identify pelvic venous reflux directly refluxing venous blood into leg varicose veins and showed this prevalence to be approximately 3% of males presenting with leg varicose veins to our clinic. We drew parallels with our previous research showing the same pattern in approximately 20% of females ⁴ and the association this has with recurrent varicose veins. ³

Ozturk and Yetkin are quite correct that we should have reported the presence of varicocele in these patients and we thank them for this opportunity to do so (Table 1). Interestingly, this shows that although there were eight incompetent testicular veins in this series, only five were associated with significant varicoceles on the same side. Of the three that were unrelated to significant varicoceles, two showed minor testicular varices on ultrasound only, that were clinically insignificant and one showed no varicocele at all.

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Table 1.

The presence or absence of a varicocele, and the pattern of pelvic venous reflux, in the eight patients presented in Dabbs et al. ²

Patient	Presence of varicocele	Pattern of pelvic vein reflux
		Testicular vein (TV)	Internal iliac vein (IIV)
1	Bilateral varicoceles	Bilateral TV	Bilateral IIV
2	No varicocele	Left TV	Bilateral IIV
3	No varicocele		Right IIV
4	No varicocele (minor left varices on ultrasound but not significant)	Left TV	Bilateral IIV
5	No varicocele		Bilateral IIV
6	Left varicocele	Left TV	Bilateral IIV
7	No varicocele (minor right varices on ultrasound but not significant)	Right TV	Bilateral IIV
8	Bilateral varicoceles	Bilateral TV	Bilateral IIV

Despite their assertion that our observation is not new, the reference that they provide ⁵ does not support their claim. The quoted study was merely an observational study showing that males with clinical varicoceles are likely to have varicose veins. The authors did not show, nor attempt to show, a direct link of venous reflux from pelvic varicose veins to leg varicose veins – they merely suggested that the coexistence of both conditions in the same patient points to a common mechanism of development. Indeed they conclude “the presence of peripheral varicose veins is positively associated with varicocele, suggesting a possible common pathologic mechanism. Therefore, we recommend that men with a predisposition to leg varicose veins should also be examined for varicocele.” ⁵

This is completely different from our paper which shows a direct link of venous reflux from incompetent pelvic veins (including the testicular vein) into incompetent leg veins that are causing leg varicose veins and in one case, a leg ulcer. This does appear to be a new finding, particularly the fact that there can be a reflux pathway from testicular vein to leg varicose veins, and the suggestion that males may need to have pelvic veins assessed and treated as part of leg varicose veins treatment does appear to be novel. If this has been described before, then Ozturk and Yetkin have failed to prove it.

In conclusion, we agree with Ozturk and Yetkin that there is increasing evidence that varicose veins are associated with other dilating cardiovascular conditions such as varicocele and coronary artery dilation. However, we reject their assertion that our proven cases of a direct reflux pathway from pelvic vein reflux, from both testicular and internal iliac veins, into clinically significant leg varicose veins has been shown before, nor that it has previously been suggested that these veins may need investigation and treatment as part of the treatment of leg varicose veins and associated conditions such as venous leg ulcer.