Round ligament varices (RLV) are tortuous and dilated veins in the round ligament of the uterus and are an uncommon pathology, mostly seen in pregnancy.

Clinical presentation

Unilateral or bilateral inguinal mass with or without pain almost always in pregnant patients. When the swelling is painful, the clinical suspicion of a strangulated inguinal hernia is high ¹.

Pathology

Round ligament varices arise from the veins draining the round ligament of the uterus and the inguinal canal into the inferior epigastric vein:

• Increased blood volume, venous return, and progesterone levels during pregnancy cause venous dilation and muscle relaxation ¹

• the gravid uterus is an obstacle to venous blood flow that contributes to the formation of round ligament varices in pregnancy ²

Radiographic features

Ultrasound

Typical findings on ultrasound include ¹:

• the "bag of worms" appearance in the subcutaneous tissue with multiple dilated veins extending through the inguinal canal that increases in standing position and on Valsalva maneuver ¹

• visible venous flow on Color Doppler increasing upon a Valsalvamanoeuvrer and in the standing position ¹

Differential diagnosis

• hydrocele of the canal of Nuck

• extra genital endometriosis

• subcutaneous lipoma

• lymphadenopathy

• vascular aneurysm

• soft tissue malignancies

• abscess formation

• inguinal hernia

Treatment and prognosis

Usually, treatment of round ligament varices is conservative and in most cases, they resolve spontaneously after delivery ³. During pregnancy, they feature a high risk of recurrence and are not an indication for surgery or cesarean section before or after delivery ^2,3.