Symptomatic iliac fossa and suprapubic varicosities are uncommon presentations in adults. Such presentations often point to acquired obstructive process to pelvic outflow or to the progression of venous insufficiency and reflux in the pelvic and gonadal veins. Less frequently, venous anomalies of the renal veins or IVC might be implicated. Furthermore, late presentations of congenital or acquired developmental abnormalities might become manifest. As this case illustrates, a thorough understanding of the underlying pathologic process and the anatomical derangement must be sought before any treatment is instituted. Unnecessary extirpation of these varicosities would simply have removed vital physiologic cross-pelvic collateral circulation from the lower extremity in the face of chronic iliac vein occlusion.