
==== Front
Cureus
Cureus
2168-8184
Cureus
2168-8184
Cureus Palo Alto (CA)

10.7759/cureus.67687
General Surgery
Prevalence of Varicose Veins Among Surgeons: A Cross-Sectional Study
Muacevic Alexander
Adler John R
Qari Turki A 1
Almatrafi Khaled N 1
Khateb Fawaz R 1
Al-Kaabi Bader 1
Al-Harbi Ahmed 1
Alabdali Samer 1
Al-nemari Rashed 1
Bannani Sahar A 23
1 Medicine and Surgery, Umm Al-Qura University, Makkah, SAU
2 Surgery, Umm Al-Qura University, Makkah, SAU
3 Surgical Oncology, King Abdullah Medical City, Makkah, SAU
Turki A. Qari turkiqari0@gmail.com
24 8 2024
8 2024
16 8 e6768724 8 2024
Copyright © 2024, Qari et al.
2024
Qari et al.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article is available from https://www.cureus.com/articles/273881-prevalence-of-varicose-veins-among-surgeons-a-cross-sectional-study
Background

Extended periods of standing, obesity, female sex, and older age are risk factors associated with a higher probability of developing varicose veins (VV). This study aimed to determine the prevalence of VV among surgeons in public hospitals in Makkah, Saudi Arabia, and to identify the risk factors associated with this condition. 

Methodology

This is a descriptive cross-sectional study based on a validated online questionnaire distributed via hospital WhatsApp (Meta Platforms Inc., Menlo Park, CA) groups conducted between January and June 2024. The inclusion criteria of this study were surgeons of both sexes and any age group working in the selected hospitals in Makkah City, who agreed to participate in the study. The exclusion criteria were any other healthcare workers from outside the surgical field. We included 192 participants, and Epi Info software (Centers for Disease Control and Prevention, Atlanta, GA) was used to calculate the sample size. The data were collected, reviewed, and then fed into IBM SPSS Statistics software for Windows version 21 (IBM Corp., Armonk, NY). Every participant filled out a consent form. The university ethics committee of Umm Al-Qura University, Makkah, granted ethical permission.

Result

This study comprised 192 surgeons in Makkah hospitals. Twenty-eight surgeons were either diagnosed with VV or had signs of VV. Varicose veins were detected among 50% of thoracic surgeons, 42.9% of pediatric surgeons, and 26.3% of orthopedic surgeons. The most reported risk factors were a family history of VV (17%), hypertension (16%), and diabetes mellitus (14%). Surgeons aged 40 years or older had a higher prevalence of VV than younger ones. Also, 55.6% of obese surgeons had VV compared to 7.8% of others with average weight.

Conclusion

We found that VV is a common problem, particularly among individuals with predisposing factors, such as long standing hours, smoking, pregnancy, and obesity. We found that surgeons specializing in thoracic and pediatric specialties and female surgeons were more likely to be affected by VV. Preventive measures, such as avoiding prolonged standing, wearing compression stockings, and maintaining a healthy lifestyle, are recommended. 

prevalence
vascular surgery
general surgery
surgeons
varicose veins
==== Body
pmcIntroduction

Worldwide, the prevalence of varicose veins (VV) ranges from 10% to 60% [1]. In Saudi Arabia, research has indicated that the occurrence of this condition is relatively high, estimated to be as much as 62%.

Furthermore, it has been observed that there is a yearly increase of around 5% in females and 2% in males [2, 3]. Valves can weaken and fail due to various factors, including venous thrombosis, heredity, and the deterioration of the venous wall's elastic tissue by chemical, mechanical, and enzymatic injuries interrupting blood vessel homeostasis [4,5]. The symptoms of the lower limb VV might be localized, affecting just that area, or they can be widespread, affecting the entire leg. While localized sensations like pain, burning, and itching are more common, other symptoms include leg pain, weariness, edema, and leg fatigue. Long durations of standing typically exacerbate symptoms; sitting and raising the legs of the patient alleviates these symptoms [6]. Complications from VV are not prevalent. However, clots in the deep veins of the legs may sometimes get bigger. These illnesses result in swelling and pain in the legs, which may require treatment when these symptoms are persistent. This increases morbidity and medical costs associated with these symptoms [7]. Because surgeons must stand and sit for extended periods during surgical operations, they are more likely to acquire VV. The main objectives of this study were to determine how common varicose veins are among surgeons in Makkah City, Saudi Arabia, and what risk factors are linked to this condition.

Materials and methods

Study design and criteria

A descriptive cross-sectional study based on a validated, self-administered online questionnaire conducted between January 2024 and June 2024 targeted surgeons of both male and female genders from different specialties in the public hospitals of Makkah. The inclusion criteria for the participating individuals were surgeons of both sexes, any age group, any nationality, with different years of employment, working in the selected hospitals, and those who had agreed to participate in the study. The exclusion criteria were any other healthcare workers from outside the surgical field, outside the selected hospitals in Makkah, or those who refused to participate.

Procedure and assessments

The items in the questionnaire were taken from earlier literature done in Saudi Arabia [8]. A pilot study with 25 individuals was conducted. To evaluate validity and reliability, the pilot study's findings were reviewed. The questionnaire covered participants' socio-demographic characteristics, such as gender, age, nationality, specialty, and years of working in the field. The second section covered lifestyle and work-related variables. The last section included participants' health-related data (comorbidities, hormonal therapy/contraceptives, etc.). Before starting the questionnaire, consent was obtained from all participants, and we excluded those who did not agree to participate in our survey. Data were gathered using Google Forms (Google Inc., Mountain View, CA) and an online, verified survey. Several potential biases could affect the study's outcomes. Selection bias may have occurred due to the convenience sampling method used, as the survey was distributed only via hospital WhatsApp (Meta Platforms Inc., Menlo Park, CA) groups, potentially excluding surgeons who were not part of these groups or were less active on WhatsApp. Response bias might be present if the surgeons who chose to participate differed significantly from those who did not, such as being more interested in the topic or having more free time to complete the survey. Information bias could arise from self-reported data, as participants might inaccurately report their socio-demographic or health-related information. However, it is important to note that we made significant efforts to mitigate these biases. We ensured anonymity and confidentiality and encouraged honest responses, all of which contributed to the credibility of our study. The participants were told about the aim of the study and the voluntary nature of their participation. The study questionnaire was available to participants until no more new answers were needed.

Ethical consideration and sample size calculation

Epi Info software (Centers for Disease Control and Prevention, Atlanta, GA) was used to calculate the sample size. The sample size calculator showed that 190 was the least suggested size for this study, with a 50% response distribution, a 5% margin of error, and a 95% confidence interval level. In addition to obtaining institutional review board (IRB) approval, several ethical considerations were addressed, underscoring our commitment to the integrity and ethical conduct of the study. Informed consent was obtained from all participants before they started the questionnaire. The consent process included informing participants about the study's purpose, the voluntary nature of their participation, and their right to withdraw at any time without any repercussions. Data confidentiality was strictly maintained; all responses were anonymized, and no personally identifiable information was collected. The data were stored securely, accessible only to the research team, and used solely for this study. Institutional Review Board approval was obtained from Umm Al-Qura University's Biomedical Research Ethics Committee with approval no. HAPO-02-K-012-2023-09-1733.

Statistical analysis

The data were collected, reviewed, and then fed into IBM SPSS Statistics software for Windows version 21 (IBM Corp., Armonk, NY). All statistical methods used were two-tailed with an alpha level of 0.05, considering significance if the p-value was less than or equal to 0.05. Descriptive analysis was done by prescribing frequency distribution and percentage for study variables, including the surgeons' personal and work data. Surgeons' habits, risk factors of VV, reported practices to prevent VV, and overall prevalence of VV were graphed. Cross-tabulation to assess the relationship between having VV and surgeons' personal data and work data, besides relationships with other factors, was carried out with Pearson's chi-square test for significance and Fisher's exact probability test if there were small frequency distributions.

Results

A total of 192 eligible surgeons in Makkah hospitals were included. Surgeons' ages ranged from 24 to 55 years, with a mean age of 33.8 ± 7.0 years old. One hundred and thirty-six (70.8%) surgeons were male, and 171 (89.1%) were Saudi nationals. As for the body mass index, 116 (60.4%) had average body weight, 67 (34.9%) were overweight, and nine (4.7%) were obese. A total of 100 (52.1%) surgeons were married, and 84 (43.8%) were single (Table 1).

Table 1 Personal characteristics of sampled surgeons from the public hospitals of Makkah, Saudi Arabia

Personal data	Frequency (%)	
Age, in years	 	
< 30	67 (34.9%)	
30-39	83 (43.2%)	
40+	42 (21.9%)	
Mean ± SD	33.8 ± 7.0	
Gender	 	
Male	136 (70.8%)	
Female	56 (29.2%)	
Body mass index	 	
Normal weight	116 (60.4%)	
Overweight	67 (34.9%)	
Obese	9 (4.7%)	
Nationality	 	
Saudi	171 (89.1%)	
Non-Saudi	21 (10.9%)	
Marital status	 	
Single	84 (43.8%)	
Married	100 (52.1%)	
Divorced	8 (4.2%)	
Number of children	 	
1-2	37 (40.7%)	
3-4	41 (45.1%)	
5+	13 (14.3%)	
Mean ± SD	2.1 ± 1.1	

Regarding specialties, 38.5% were general surgeons, 16.7% were obstetricians and gynecologists, 9.9% were orthopedic surgeons, 7.3% were pediatric surgeons, and 6.8% were neurosurgeons. The least reported specialties were vascular surgery (2.1%), colorectal surgery (1.6%), and ophthalmology (1.6%). As for the number of work years, 41.7% had worked for one to four years, and 26% worked for 10-19 years. A total of 17.2% were used to standing in surgery for less than two hours, 43.8% stood in surgery for two to four hours, and 10.4% stood for more than eight hours. On the other hand, most of the surgeons (85.9%) sat in surgery for less than two hours, and 12% sat for two to four hours. Only 22.4% reported they usually lift objects that were 23 kg or more during work time, 33.3% were smokers, and 52.1% frequently practiced sports or physical exercise less than four times a week (Table 2).

Table 2 Surgeons' work data and habits

Work data	Frequency (%)	
Specialty	 	
General surgeon	74 (38.5%)	
Obstetrician and gynecologist	32 (16.7%)	
Orthopedic surgeon	19 (9.9%)	
Pediatric surgeon	14 (7.3%)	
Neurosurgeon	13 (6.8%)	
Otolaryngologist (ENT)	11 (5.7%)	
Urologist	11 (5.7%)	
Thoracic surgeon	8 (4.2%)	
Vascular surgeon	4 (2.1%)	
Colon and rectal surgeon	3 (1.6%)	
Ophthalmologist	3 (1.6%)	
Years working in the field	 	
1-4	80 (41.7%)	
5-9	44 (22.9%)	
10-19	50 (26.0%)	
20+	18 (9.4%)	
How many hours do you stand in a surgery?	 	
< 2 hours	33 (17.2%)	
2-4 hours	84 (43.8%)	
4-6 hours	37 (19.3%)	
6-8 hours	18 (9.4%)	
> 8 hours	20 (10.4%)	
How many hours do you sit in a surgery?	 	
< 2 hours	165 (85.9%)	
2-4 hours	23 (12.0%)	
4-6 hours	2 (1.0%)	
Do you usually lift objects that are 23 kg or more during work time?	 	
Yes	43 (22.4%)	
No	149 (77.6%)	
Are you a smoker?	 	
Yes	64 (33.3%)	
No	128 (66.7%)	
Do you frequently practice sports or physical exercise?	 	
None	75 (39.1%)	
< 4 times per week	100 (52.1%)	
> 7 times per week	17 (8.9%)	

Concerning the prevalence of VV among the surgeons in the study, a total of 28 (14.6%) were either diagnosed with VV or had signs of VV, while 164 (85.4%) had normal veins. The most reported risk factors were family history of VV (17%), hypertension (16%), diabetes mellitus (14%), being on contraceptive pills (for females; 9%), chronic constipation (8%), and rheumatoid arthritis (4%) (Figure 1).

Figure 1 Risk factors and determinants of varicose veins among the surgeons in the study

The most reported preventive practices were moving the legs and flexing the ankles during operations (82.8%), performing regular light exercise (57.3%), maintaining an ideal body weight (55.2%), avoiding extended periods of sitting or standing (49.5%), elevating legs above heart level when possible (28.1%), and wearing compression stockings at work (18.2%) (Figure 2).

Figure 2 Practices reported by surgeons to prevent varicose veins

Approximately 28.6% of surgeons aged 40 years or older had VV versus 10.4% of younger surgeons (P = 0.015). Also, 55.6% of obese surgeons had VV compared to 7.8% of those with average weight (P = 0.001) (Table 3).

Table 3 The correlation between having varicose veins and surgeons' personal data

Personal data	Having varicose veins	p-value	
Yes	No	
Frequency (%)	Frequency (%)	 	
Age, in years	 	 	.015*	
< 30	7 (10.4%)	60 (89.6%)	
30-39	9 (10.8%)	74 (89.2%)	
40+	12 (28.6%)	30 (71.4%)	
Gender	 	 	.085	
Male	16 (11.8%)	120 (88.2%)	
Female	12 (21.4%)	44 (78.6%)	
Body mass index	 	 	.001*	
Normal weight	9 (7.8%)	107 (92.2%)	
Overweight	14 (20.9%)	53 (79.1%)	
Obese	5 (55.6%)	4 (44.4%)	
Nationality	 	 	.010*^	
Saudi	21 (12.3%)	150 (87.7%)	
Non-Saudi	7 (33.3%)	14 (66.7%)	
Marital status	 	 	.168	
Single	8 (9.5%)	76 (90.5%)	
Married	18 (18.0%)	82 (82.0%)	
Divorced	2 (25.0%)	6 (75.0%)	
Number of children	 	 	.947	
1-2	7 (18.9%)	30 (81.1%)	
3-4	8 (19.5%)	33 (80.5%)	
5+	3 (23.1%)	10 (76.9%)	

Varicose veins were significantly associated among 50% of thoracic surgeons, 42.9% of pediatric surgeons, 26.3% of orthopedic surgeons, and 18.2% of otolaryngologists (ENT) (P = 0.002). Also, 44.4% of surgeons with 20 years or more of experience had significantly associated VV compared to 13.8% of those with one to four years of experience (P = 0.002). Varicose veins were significantly associated among 23.3% of those who usually lifted objects that were 23 kg or more during work time versus 12.1% of those who did not (P = 0.049) (Table 4).

Table 4 The correlation between surgeons' work data and their personal data

Work data	Having varicose veins	p-value	
Yes	No	
Frequency (%)	Frequency (%)	 	
Specialty	 	 	.002*^	
Colon and rectal surgeon	0 (0.0%)	3 (100.0%)	
General surgeon	5 (6.8%)	69 (93.2%)	
Neurosurgeon	0 (0.0%)	13 (100.0%)	
Obstetrician and gynecologist	5 (15.6%)	27 (84.4%)	
Ophthalmologist	0 (0.0%)	3 (100.0%)	
Orthopedic surgeon	5 (26.3%)	14 (73.7%)	
Otolaryngologist [ENT]	2 (18.2%)	9 (81.8%)	
Pediatric surgeon	6 (42.9%)	8 (57.1%)	
Thoracic surgeon	4 (50.0%)	4 (50.0%)	
Urologist	1 (9.1%)	10 (90.9%)	
Vascular surgeon	0 (0.0%)	4 (100.0%)	
Years working in the field	 	 	.002*	
1-4 years	11 (13.8%)	69 (86.3%)	
5-9 years	4 (9.1%)	40 (90.9%)	
10-19 years	5 (10.0%)	45 (90.0%)	
20+ years	8 (44.4%)	10 (55.6%)	
How many hours do you stand in a surgery?	 	 	.268^	
< 2 hours	5 (15.2%)	28 (84.8%)	
2-4 hours	8 (9.5%)	76 (90.5%)	
4-6 hours	9 (24.3%)	28 (75.7%)	
6-8 hours	2 (11.1%)	16 (88.9%)	
> 8 hours	4 (20.0%)	16 (80.0%)	
How many hours do you sit in a surgery?	 	 	.099^	
< 2 hours	20 (12.1%)	145 (87.9%)	
2-4 hours	7 (30.4%)	16 (69.6%)	
4-6 hours	1 (50.0%)	1 (50.0%)	
6-8 hours	0 (0.0%)	1 (100.0%)	
> 8 hours	0 (0.0%)	1 (100.0%)	
Do you usually lift objects that are 23 kg or more during work time?	 	 	.049*	
Yes	10 (23.3%)	33 (76.7%)	
No	18 (12.1%)	131 (87.9%)	
Are you a smoker?	 	 	0.112	
Yes	13 (20.3%)	51 (79.7%)	
No	15 (11.7%)	113 (88.3%)	
Do you frequently practice sports or physical exercise?	 	 	0.09	
No	16 (21.3%)	59 (78.7%)	
< 4 times per week	11 (11.0%)	89 (89.0%)	
> 7 times per week	1 (5.9%)	16 (94.1%)	

Among all included factors, VV was significantly associated higher among those with a family history of VV (36.4% vs. 10.1%, P = 0.001), deep vein thrombosis (66.7% vs. 13.8%, P = 0.010), hypertension (32.3% vs. 11.2%, P = 0.002), rheumatoid arthritis (50% vs. 13%, P = 0.004), and contraceptive use (60% vs. 17.6%, P = 0.028). The condition of VV was significantly associated with lower among surgeons performing regular light exercise (10% vs. 20.7%, P = 0.037) and those maintaining an ideal body weight (8.5% vs. 22.1%, P = 0.008) (Table 5).

Table 5 Other factors associated with the occurrence of varicose veins among surgeons

Other factors	Having varicose veins	p-value	
Yes	No	
Frequency (%)	Frequency (%)	 	
Family history of varicose veins	Yes	12 (36.4%)	21 (63.6%)	.001*	
No	16 (10.1%)	143 (89.9%)	
Deep vein thrombosis (DVT)	Yes	2 (66.7%)	1 (33.3%)	.010*	
No	26 (13.8%)	163 (86.2%)	
Coronary artery disease	Yes	1 (16.7%)	5 (83.3%)	.883	
No	27 (14.5%)	159 (85.5%)	
Hypertension	Yes	10 (32.3%)	21 (67.7%)	.002*	
No	18 (11.2%)	143 (88.8%)	
Chronic constipation (infrequent bowel movement for weeks at a time)	Yes	6 (40.0%)	9 (60.0%)	.004*	
No	22 (12.4%)	155 (87.6%)	
Diabetes	Yes	7 (25.9%)	20 (74.1%)	.072	
No	21 (12.7%)	144 (87.3%)	
Kidney disease	Yes	2 (33.3%)	4 (66.7%)	.186	
No	26 (14.0%)	160 (86.0%)	
Rheumatoid arthritis	Yes	4 (50.0%)	4 (50.0%)	.004*	
No	24 (13.0%)	160 (87.0%)	
Severe occupational injury to the lower extremities	Yes	1 (33.3%)	2 (66.7%)	.354	
No	27 (14.3%)	162 (85.7%)	
Are you on hormonal therapy?	Yes	1 (50.0%)	1 (50.0%)	.154	
No	27 (14.2%)	163 (85.8%)	
Are you on contraceptive pills?	Yes	3 (14.2%)	2 (40.0%)	.028*	
No	9 (17.6%)	42 (82.4%)	
Do you usually wear compression stockings at work?	Yes	6 (17.1%)	29 (82.9%)	.635	
No	22 (14.0%)	135 (86.0%)	
Do you elevate your legs above your heart when possible?	Yes	7 (13.0%)	47 (87.0%)	.691	
No	21 (15.2%)	117 (84.8%)	
Do you move your legs and flex your ankles during the operation?	Yes	21 (13.2%)	138 (86.8%)	.236	
No	7 (21.2%)	26 (78.8%)	
Do you perform regular light exercise?	Yes	11 (10.0%)	99 (90.0%)	.037*	
No	17 (20.7%)	65 (79.3%)	
Do you avoid extended periods of sitting or standing?	Yes	16 (16.8%)	79 (83.2%)	.380	
No	12 (12.4%)	85 (87.6%)	
Do you maintain an ideal body weight?	Yes	9 (8.5%)	97 (91.5%)	.008*	
No	19 (22.1%)	67 (77.9%)	

Discussion

Varicose veins are a condition involving the lower limbs, a common problem affecting a portion of the general population [9], especially those who have predisposing factors for VV, such as obesity, smoking, pregnancy, and long hours spent standing [10-12].

In our study, 28 surgeons were either diagnosed with VV or had signs of VV. One known risk factor for venous disease development is older age; the prevalence of venous illness rises with aging. In line with this, 28.6% of surgeons aged 40 years or more had VV versus 10.4% of surgeons aged less than 40 years. These results are similar to a previous study conducted in Abha, Saudi Arabia, where the most common age group with VV was 36 to 45 years old [13]; this may be brought on by a weakening of the calf muscles, which over time causes the vessel walls to deteriorate gradually and increases pressure on superficial veins [14]. Our study found the highest prevalence of VV in thoracic surgeons (50%), followed by pediatric surgeons (42.9%), and orthopedic surgeons (26.3%); a potential association exists between prolonged periods of intraoperative standing and the observed outcomes. Conversely, the lowest VV prevalence was in vascular and colorectal surgeons (0%). This could be attributed to vascular surgeons' extensive knowledge and expertise regarding VV, leading to heightened awareness and proactive preventative measures.

In this study, there was a noteworthy distinction in the diagnosis of VV between male and female surgeons, with 11.8% of males and 21.4% of females diagnosed. Gender is one of the contributing factors for VV [15]. Likewise, several earlier studies found that women are more likely than men to develop VV [16-18]. The hormones progesterone and estrogen may impact women's propensity to develop VV. When progesterone attaches to its receptor on the venous walls, it decreases collagen synthesis and causes the smooth muscle in the veins to become hypotonic [19].

Most of the surgeons involved in our study would stand for two to four hours in a surgery (n = 84). The results showed that 9.5% of those surgeons were diagnosed with VV. For surgeons who stood for more than eight hours in a surgery (n = 20), 20% were diagnosed with VV, which is the highest percentage. In a study by Krijnen et al., standing position was an exacerbating factor for VV in the European population [20]. Nia et al. found that nurses who stand for longer than four hours had four times higher odds of developing VVs compared to those who stand for shorter periods [21].

Exercise strengthens the lower limb muscles, particularly the gastrocnemius, which has an excellent pumping action. Additionally, regular physical activity keeps blood flow healthy and prevents venous stasis [13]. Our study showed that individuals who regularly performed light exercise for at least four hours per week showed a lower propensity to develop VV than individuals who were either irregular or did not exercise. Additionally, surgeons reported some practices to prevent VVs. The most common preventive practices were moving their legs and flexing ankles during operation, avoiding prolonged sitting or standing, and wearing compression stockings while at work.

According to our study, the diagnosis rate for surgeons with a family history of VV was 36.4%, which is much higher than the rate for surgeons without a family history (10.1%). Although specific genes are yet unknown, several studies have shown that family history is a significant risk factor for vein disorders. [22-24].

Strengths

This study provides valuable insights into the prevalence of VV among surgeons in Makkah, Saudi Arabia. We consider it a large city and include a lot of surgeons and a wide range of specialties, so we identified those most affected and developed targeted prevention plans.

Limitations

One of the study's limitations is the small sample size. The research on changes in VV over time was not possible due to the cross-sectional design. Furthermore, we were unsuccessful in determining the individuals' workout and lifestyle routines. Moreover, because this study only included surgeons from one city, its conclusions might not apply to other demographics.

Conclusions

This cross-sectional study found that VV in Makkah is a common problem, particularly among individuals with predisposing factors such as obesity, smoking, pregnancy, and standing for long hours. Additionally, age, gender, duration of standing during surgery, and family history were identified as significant factors associated with VV diagnoses. We found that surgeons specializing in thoracic and pediatric specialties and female surgeons were more likely to have VV. The study emphasizes the importance of increased awareness, education, and preventive measures to address VV among surgeons. We recommend that surgeons at risk for VV take precautions, such as reducing standing time in the operating room, bringing chairs in the operating room, wearing compression stockings, and engaging in leg movement when standing is necessary. Adopting a healthy lifestyle is also advised. Further research and initiatives are needed to enhance prevention and management strategies for this condition.

Disclosures

Author Contributions

Human subjects: Consent was obtained or waived by all participants in this study. Umm Al-Qura University's Biomedical Research Ethics Committee issued approval (HAPO-02-K-012-2023-09-1733).

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Concept and design:  Turki A. Qari, Khaled N. Almatrafi, Fawaz R. Khateb , Samer Alabdali, Ahmed Al-Harbi, Bader Al-Kaabi, Rashed Al-nemari, Sahar A. Bannani

Acquisition, analysis, or interpretation of data:  Turki A. Qari, Khaled N. Almatrafi, Fawaz R. Khateb , Samer Alabdali, Ahmed Al-Harbi, Bader Al-Kaabi, Rashed Al-nemari, Sahar A. Bannani

Drafting of the manuscript:  Turki A. Qari, Khaled N. Almatrafi, Fawaz R. Khateb , Samer Alabdali, Ahmed Al-Harbi, Bader Al-Kaabi, Rashed Al-nemari, Sahar A. Bannani

Critical review of the manuscript for important intellectual content:  Turki A. Qari, Khaled N. Almatrafi, Fawaz R. Khateb , Samer Alabdali, Ahmed Al-Harbi, Bader Al-Kaabi, Rashed Al-nemari, Sahar A. Bannani

Supervision:  Sahar A. Bannani
==== Refs
References

1 Chronic venous insufficiency: prevalence and effect of compression stockings Int J Health Sci (Qassim) Al Shammeri O AlHamdan N Al-Hothaly B Midhet F Hussain M Al-Mohaimeed A 231 236 8 2014 https://doi.org/10.12816/0023975 25505858
2 Varicose veins; outcome of surgical management and recurrences Professional Med J Das K Ahmed S Abro S Arain MS 509 513 21 2014 https://theprofesional.com/index.php/tpmj/article/download/2014/1661
3 Varicose veins and lower extremity venous insufficiency Semin Intervent Radiol DePopas E Brown M 56 61 35 2018 29628617
4 Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings Radiographics Jung SC Lee W Chung JW 525 536 29 2009 https://doi.org/10.1148/rg.292085154 19325063
5 Association between varicose veins anatomical pattern and procedural complications following endovascular laser photothermolysis for chronic venous insufficiency Braz J Med Biol Res Molnar C Opincariu D Benedek T Toma M Nicolescu C 0 52 2019 https://doi.org/10.1590/1414-431x20198330
6 Current advances in the pathogenesis of varicose veins J Surg Res Naoum JJ Hunter GC Woodside KJ Chen C 311 316 141 2007 https://doi.org/10.1016/j.jss.2006.08.007 17070551
7 Vascular wall extracellular matrix proteins and vascular diseases Biochim Biophys Acta Xu J Shi GP 2106 2119 1842 2014 https://doi.org/10.1016/j.bbadis.2014.07.008 25045854
8 Prevalence of varicose veins among nurses in different departments in Jazan public hospitals, Saudi Arabia: a cross-sectional study Cureus Ali SA Najmi WK Hakami FM 0 14 2022
9 Evaluating the prevalence and risk factors of varicose veins in surgeons and operating room staff at Buraidah Center Hospital Cureus Almutiri BM Alshammari AM Alharbi SB Alamri LM Alsuhaibani AN Alenazi RS Alfarhan GK 0 16 2024
10 Prevalence of varicose veins among nurses at different departments in a single tertiary care center in Riyadh Cureus AlBader B Sallam A Moukaddem A Alanazi K Almohammed S Aldabas H Algmaizi S 0 12 2020
11 Epidemiology and risk factors for varicose veins among older people: cross-sectional population study in the UK Phlebology Clark A Harvey I Fowkes FG 236 240 25 2010 https://doi.org/10.1258/phleb.2009.009045 20870870
12 Prolonged standing at work and hospitalisation due to varicose veins: a 12 year prospective study of the Danish population Occup Environ Med Tüchsen F Hannerz H Burr H Krause N 847 850 62 2005 https://doi.org/10.1136/oem.2005.020537 16299093
13 Prevalence and awareness of varicose veins among teachers in Abha, Saudi Arabia J Family Med Prim Care Dalboh A Alshehri NA Alrafie AA Bakri KA 4784 4787 9 2020 https://doi.org/10.4103/jfmpc.jfmpc_490_20 33209801
14 The epidemiology of chronic venous insufficiency and varicose veins Ann Epidemiol Beebe-Dimmer JL Pfeifer JR Engle JS Schottenfeld D 175 184 15 2005 https://doi.org/10.1016/j.annepidem.2004.05.015 15723761
15 Standing posture at work and overweight exacerbate varicose veins: Shimane CoHRE Study J Dermatol Kohno K Niihara H Hamano T 964 968 41 2014 25298232
16 The epidemiology of varicose veins: the Framingham Study Am J Prev Med Brand FN Dannenberg AL Abbott RD Kannel WB 96 101 4 1988 https://pubmed.ncbi.nlm.nih.gov/3395496/ 3395496
17 The influence of environmental factors in chronic venous insufficiency Angiology Jawien A 0 31 54 Suppl 1 2003 https://doi.org/10.1177/0003319703054001S04
18 Chronic venous disease in an ethnically diverse population: the San Diego Population Study Am J Epidemiol Criqui MH Jamosmos M Fronek A Denenberg JO Langer RD Bergan J Golomb BA 448 456 158 2003 https://doi.org/10.1093/aje/kwg166 12936900
19 Physical exercise for the treatment of non-ulcerated chronic venous insufficiency Cochrane Database Syst Rev Araujo DN Ribeiro CT Maciel AC Bruno SS Fregonezi GA Dias FA 0 12 2016 https://doi.org/10.1002/14651858.CD010637.pub2
20 Venous insufficiency in male workers with a standing profession. Part 1: epidemiology Dermatology Krijnen RM de Boer EM Adèr HJ Bruynzeel DP 111 120 194 1997 https://doi.org/10.1159/000246077 9094457
21 Varicose veins of the legs among nurses: occupational and demographic characteristics Int J Nurs Pract Sharif Nia H Chan YH Haghdoost AA Soleimani MA Beheshti Z Bahrami N 313 320 21 2015 https://doi.org/10.1111/ijn.12268 24689446
22 Risk indicators for varicose veins in forty- to sixty-year-olds in the Tampere varicose vein study World J Surg Laurikka JO Sisto T Tarkka MR Auvinen O Hakama M 648 651 26 2002 https://doi.org/10.1007/s00268-001-0283-1 12053212
23 Work conditions as risk factors for varicose veins of the lower extremities in certain professions of the working population of Rijeka Acta Med Okayama Kontosić I Vukelić M Drescik I Mesaros-Kanjski E Materljan E Jonjić A 33 38 54 2000 https://doi.org/10.18926/AMO/32311 10709620
24 Risk factors for the first-time development of venous ulcers of the lower limbs: the influence of heredity and physical activity Angiology Bérard A Abenhaim L Platt R Kahn SR Steinmetz O 647 657 53 2002 https://doi.org/10.1177/000331970205300604 12463617
