Compression and Superficial Varicosities Outperform Gonadal Vein Diameter in Differentiating Symptomatic from Asymptomatic Pelvic Venous Disorders: A Case–Control Study

PURPOSE: To assess whether gonadal vein (GV) diameter associates with pelvic venous disorder (PeVD)-consistent symptoms in women with pelvic varices, compared with proximal venous outflow obstruction (VOO; iliac/left renal vein stenosis/obstruction) and superficial varicosities. MATERIALS AND METHODS: This retrospective, case-control study identified patients with abdominopelvic imaging (2013-2024) showing parauterine/pelvic varices > 5 mm and documentation within ± 12 months for symptom adjudication. GV diameter was measured on venous-phase computed tomography/magnetic resonance imaging by two readers, or from ultrasound when unavailable. Proximal VOO was ascertained by highest-confidence available testing and evaluated with logistic regression. RESULTS: Of 200 patients (mean age, 52.4 ± 17.0 years), 84 (42.0%) were symptomatic and 116 (58.0%) asymptomatic. Mean GV diameter did not differ by symptom status (8.89 ± 2.29 vs 9.43 ± 2.50 mm; P = 0.121) and was not associated with symptoms in crude (odds ratio [OR], 0.91 per mm; 95% confidence interval [CI], 0.80-1.03) or adjusted analysis (adjusted OR [aOR], 0.97 per-mm; 95% CI, 0.81-1.14). Proximal VOO was assessable in 189 patients and more common in symptomatic vs asymptomatic patients (32.9% vs 2.6%; P < 0.001), as were lower-extremity (LE) varices (44.0% vs 12.9%; P < 0.001) and superficial pelvic varicosities (28.6% vs 1.7%; all P < 0.001). In the adjusted model, younger age (aOR, 0.50 per 10 years; 95% CI, 0.39-0.65), LE varices (aOR, 9.80; 95% CI, 3.76-25.50), and any proximal VOO (aOR, 10.89; 95% CI, 2.66-44.55) were independently associated with symptomatic status. Discrimination was acceptable (c-statistic, 0.82; 95% CI, 0.76-0.89) and unchanged by GV diameter. CONCLUSION: Among women with pelvic varices, GV diameter was not associated with PeVD-consistent symptoms and added no incremental predictive value beyond age, LE varices, and VOO. Comorbid venous disease and outflow obstruction may better distinguish clinically significant PeVD than diameter thresholds alone.