Trans-vaginal ultrasound (TVU) is a way of assessing the pelvic veins. It should be performed in women when a reflux source is suspected arising from above the sapheno-femoral junction. Approximately a sixth of women have a refluxive saphenous vein fed from above. Accurate evaluation of all reflux sources is essential to direct durable treatment options. Common sites of pelvic venous reflux (PVR) include the internal iliac vein, pudendal, obturator, rectal, epigastric and perineal veins, the uterine venous plexus and occasionally the ovarian veins. Reconciling pelvic venous reflux with varicose veins is a grossly under researched area.