Vulval varicosity in pregnancy: Clinical recognition and diagnostic clues

A 29-year-old second gravida at 37 weeks of gestation presented with swelling over the genital region for the past month, associated with a feeling of heaviness and vaginal discomfort. There was no history of itching, bleeding, or ulceration. The patient denied similar complaints in her first pregnancy.

On examination, a tortuous bluish swelling resembling a “cluster of grapes” was noted over the right labia majora with no overlying skin changes, consistent with distended veins. [Figure 1a and b]. Palpation revealed a “bag of worms” sensation. The veins partially emptied on manual compression but refilled immediately upon release of pressure. [Figure 1c]. There was no inguinal lymphadenopathy or varicosities noted over the lower limbs or abdomen, and digital rectal examination ruled out hemorrhoids. A diagnosis of vulval varicocele was made and confirmed with the help of ultrasonography which showed dilated and tortuous, hypoechoic structures over the labia majora with color Doppler showing low flow vascularity. Dermoscopy of the lesion showed bluish vascular structures with few red dots, emphasizing the vascular nature of the lesion.

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Figure 1: (a and b) Examination revealed a bluish, tortuous swelling over the right labia majora resembling a “cluster of grapes.” (c) Partially emptied veins on manual compression, refilling immediately after release.

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The patient was managed conservatively with compression undergarments and was reassured about the potential spontaneous resolution after delivery, which was evident on her post-partum follow-up visit at 4 weeks [Figure 2].

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Figure 2: Post-partum clinical image showing complete resolution of lesions.

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