Water retention (edema) in the legs

What is it about ?

Fluid retention (or edema) can occur in one or both legs. It can be due to different underlying conditions or abnormalities, which often occur together. In people over 50, varicose veins are the most common cause. Due to the malfunction of the valves of the leg veins, the transport of blood from the lower limbs to the heart does not take place properly. Another possible cause is a decrease in heart function ( heart failure ), due to which blood is no longer distributed properly throughout the body. Edema can also be caused by taking medications, including certain medications for high blood pressure.

Where and how often?

In Europe and the United States, 25 to 30 in every 100 adult women and about 15 in 100 adult men suffer from varicose veins .
The heart failure increases with age. In the Netherlands, in the 15-64 age group, only 1.8 men in a thousand and 1.3 women in a thousand suffer from heart failure. Over the age of 65, 39.3 out of 1,000 men and 46.5 out of 1,000 women suffer from heart failure. And these numbers increase even after the age of 85, rising to 113.1 men in a thousand and 116.3 women in a thousand.

How to recognize it?

If you suffer from swelling in one or both legs, it may be fluid retention (edema). Depending on the rate of development and the location of fluid retention, some causes are more likely than others.

Sudden onset of edema in both legs

Sudden onset of edema in both legs may indicate:

• the presence of a blood clot in a large vein located downstream (therefore higher, for example in the pelvis), which hinders the drainage of fluid from both legs.
• sudden deterioration of heart failure , which causes less blood flow through the body. This situation requires immediate treatment. The edema can spread to the lungs and cause a rapid increase in shortness of breath (dyspnea). This is a potentially life-threatening situation.
• sudden onset or sudden deterioration of kidney disease.

Sudden onset of edema in one leg

Sudden onset of edema in one leg may indicate:

• the presence of a blood clot (thrombosis) in a deep vein in the leg ( deep vein thrombosis ). This problem must be identified and dealt with promptly. Indeed, a piece of clot can break off (embolus) and travel with the blood to the heart and then to the lungs. In this case, there is a decrease in the exchange of oxygen (O ₂ ) and carbon dioxide (CO ₂ ) in the lungs and shortness of breath (dyspnea) may occur. If, because of this embolism ( pulmonary embolism), a large part of the lungs no longer receive blood, the situation can be life-threatening. Deep vein thrombosis can occur after a long period of time spent in a sitting or lying position (for example flying in an airplane, bed rest due to illness, plaster cast following a fracture, surgery resulting in temporary partial or complete immobilization, etc.) . Deep vein thrombosis usually causes painful swelling of the leg; the affected leg is often warmer to the touch than the other leg. If you have deep vein thrombosis, you may develop varicose veins in the affected leg, which will lead to chronic water retention in that leg.
• the sudden rupture of a “Baker’s cyst”. It is a benign, fluid-filled tumor located at the back of the knee (in the popliteal fossa). Following its rupture, the fluid drains into the surrounding tissues and accumulates in the calf.
• a skin infection in the lower part of the leg. In this case, there may be a fever, generally feeling unwell, red and hot skin at the swelling area, and pain.
• a “compartment syndrome”. The muscles at the front of the lower leg are surrounded by an inextensible membrane. The space delimited by this membrane, and which contains muscles, vessels and nerves, is called a compartment. When swelling occurs inside this pocket (for example after strenuous sporting activity), the space inside this pocket becomes too narrow, preventing blood from flowing back up and causing fluid to build up. in the lymphatic vessels of the calf. It’s painful. In severe cases, urgent surgery is needed to cut the membrane and thus prevent muscles and nerves from dying. Compartment syndrome can also be the consequence of a crush injury due to an accident, a broken leg,

Progressive onset of persistent edema in both legs

The gradual onset of persistent edema in both legs may indicate:

• edema with no apparent cause (idiopathic). It is the most common water retention in the legs in women between the ages of 20 and 30. Often the edema affects the lower limbs, but also the whole body, especially the face and hands. The person’s weight can increase by a kilogram or even more over the day.
• “premenstrual syndrome”: edema appears a few days before menstruation, possibly leading to weight gain.
• the presence of varicose veins due to a malfunction of the valves of the veins of the legs. Edema decreases at night and increases during the day, as well as with prolonged standing or sitting and in hot weather. The edema is maximum in the evening and can be painful. The following may appear later: visible varicose veins, discoloration (brown) of the skin inside the ankles, itching, dry, peeling (scaly) skin, hair loss, dilation of fine blood vessels and possibly leg ulcers.
• a heart failure . This mainly affects the elderly or people with underlying (known) heart disease. It causes a gradual increase in water retention in the lower limbs. The person is out of breath more quickly on exertion and gets tired more quickly. In a more advanced stage of heart failure, respiratory distress can be fatal. If you suffer from heart failure and notice rapid weight gain (within a few days), you should contact your doctor urgently.
• taking certain medications, including against hypertension, anti-inflammatory drugs, certain antidiabetics, corticosteroids, sex hormones (contraceptive pill), …
• lymphedema, which may be due to a genetic predisposition or the absence of certain lymphatic vessels. If this is the case, you usually had problems when you were a child or young adult. Lymphedema can also develop after infection, cancer, surgery, or radiation therapy to the lower abdomen or pelvis. At first it is still possible to flatten the swelling in the hand, but at a later stage it becomes incompressible.
• pregnancy, high blood pressure during pregnancy (pre-eclampsia), obesity, certain kidney diseases, certain liver problems (among others due to alcohol abuse), a tumor in the belly (cancer of the prostate, kidney cancer, ovarian cancer, lymphoma) which puts pressure on the blood vessels, a history of radiation therapy, anemia, a lack of protein in the blood (for example in case of liver and kidney disease ), a very lazy thyroid (severe hypothyroidism).
  Gradual and persistent water retention can also occur in the elderly and paralyzed people who sit for a long time with their knees bent, preventing blood from returning properly to the heart.

More gradual onset of persistent edema in one leg

The more gradual onset of persistent edema in one leg may indicate:

• a malfunction of one or more valves in one or more veins in the leg (valve disease). In this case, the blood cannot flow back to the heart properly and the veins can dilate ( varicose veins ).
• lymphedema. In this case, it is the lymph which cannot rise correctly to the upper part of the body (poor lymphatic drainage). This problem may be due to a genetic predisposition, external pressure on the lymphatic vessels, or an obstruction caused by infection.
• pressure exerted on the veins and / or lymphatic vessels by a tumor in the lower abdomen.

How is the diagnosis made?

Discussion

The doctor will ask you questions about your symptoms:

• How long has the swelling been present?
• how fast has it grown? Does it disappear or does it decrease overnight?
• do you also have pain or cramps in your legs?
• do you have heavy legs?
• do you feel itchy in your legs?
• do you quickly get tired or short of breath when you exert yourself?
• are you still able to sleep fully lying down or do you suffer from shortness of breath when you lie down?
• what illnesses or procedures have you suffered?
• What medications do you take ?

Physical examination

The doctor will also do a thorough clinical examination:

• it will measure and compare the circumference of your two legs at the most swollen place;
• he will look for the presence of discolorations, varicose veins , dilated blood vessels or leg ulcers;
• it will take and compare the temperature of your legs;
• he will press with a finger in the edema and observe whether the finger mark remains or not.
• it will check your heart and lungs for heart disease and heart failure (which can cause pulmonary edema).

Other examinations

The doctor may order certain blood tests. One of them, the search for D-Dimers, is used to detect the presence of a clot, for example in the deep veins ( deep vein thrombosis ). If the test is positive, it may indicate thrombosis. If the test is negative and there is no risk factor for deep vein thrombosis, it can be concluded that there is no blood clot in these veins.

If your doctor suspects deep vein thrombosis, your doctor may order or perform a Doppler exam. This test measures blood flow through the vessels.

If he suspects a tumor in the lower abdomen, the doctor will give you an ultrasound or a scan of the abdomen.

If he suspects heart failure , he will order an electrocardiogram ( ECG ). This test measures the heart’s electrical signals and is used to detect possible heart disease.

A chest x-ray will also be taken. The heart is often larger than normal in heart failure.

What can you do ?

Walking and physical exercise improve muscle pump function and strengthen leg muscles. This allows blood to flow back up to the legs better.

If you have varicose veins , it is important to avoid sitting or standing for long periods of time without moving. You can do small exercises to improve the muscle pump function of your calves: stand on your tiptoes then stand on your heels, and do so 15 times in a row. Do this a few times a day. On a long drive, stop regularly and walk a bit. On a long plane flight or long train trip, get up regularly to take a few steps and drink enough. If you are overweight, try to lose the extra pounds.

Stop smoking. Smoking increases the risk of thrombosis, especially if you are taking birth control pills.

Do not wear stockings or socks whose elastic is too tight and blocks your circulation. Choose shoes that don’t tighten and don’t rub anywhere. The shoes may tighten more if the feet are swollen. As for friction, it can cause small skin wounds which can become infected and hardly heal. Wash your feet well and take good care of your nails.

If your doctor prescribes medicines for you to treat heart failure or thyroid problems, take them regularly.

If you have varicose veins , regularly elevate your legs, knees slightly bent, and take regular breaks.

If certain special stockings are prescribed, carefully follow the advice for use. So, for example, they should be put on in the morning when you wake up. Replace them regularly (at least every six months), as they gradually stretch and are therefore less effective.

Please also tell your doctor about any medications you are taking.

What can your doctor do?

The treatment your doctor will start depends on the cause of the fluid retention.

In the case of heart failure , your doctor will prescribe medication, including water pills. Take them regularly and continue to take them even if your symptoms have disappeared. If you stop taking them you may have a sudden relapse, which could be fatal.

In the case of varicose veins and insufficient blood return from the lower limbs to the heart, the doctor may prescribe a compression bandage or compression stockings. There are different classes of compression stockings depending on the level of compression; the class should ideally be tailor-made by the bandager. Your doctor will prescribe the appropriate class of compression depending on the stage and severity of your varicose veins. A nurse can teach you how to properly apply a compression bandage. The doctor may prescribe physiotherapy sessions, where you will learn some exercises to improve the muscle pump function of the calves. Diuretics are not indicated in the treatment of varicose veins. Their effectiveness is very limited, and their side effects are more important than the benefits that one could get from them. Other drugs are also not very effective against varicose veins. In advanced stages, varicose veins can be treated surgically.

In the case of idiopathic edema (without a known cause), a few simple measures are usually sufficient: rest with raised legs, avoid heat, limit salt intake, drink in moderation, lose weight if you are overweight. If you suffer from severe swelling, your doctor may prescribe a diuretic.

In the case of lymphedema , physical activity, rest with the legs elevated, a pressure bandage or compression stockings, or manual lymphatic drainage can provide relief. Manual lymphatic drainage is performed by the physiotherapist; he evacuates the accumulated lymph thanks to his hands, by alternating pressures. The physiotherapist can also use a particular device which also exerts pressure alternately. It is necessary to have your feet checked regularly, in order to detect and treat a possible infection by fungi (mycosis), as well as to ensure a good hygiene of the feet. Diuretics have no effect on lymphedema.

If you have a blood clot in a deep vein in your leg ( deep vein thrombosis ), your doctor will give you injection medicine that thin the blood from the injections (anticoagulant). A compression bandage will then be applied and, as soon as the water retention is gone, you will wear compression stockings for two years.

You will be referred to a specialist in the following cases:

• suspected heart failure,
• suspicion of deep vein thrombosis,
• signs suggesting cancer or cancer recurrence in the lower abdomen,
• serious condition requiring further testing, such as liver disease, kidney disease or hypothyroidism.