From the Guidelines
Nutcracker syndrome symptoms typically include postprandial epigastric pain, nausea/vomiting, and loss of weight, as well as flank pain, blood in the urine (hematuria), and pelvic congestion. Patients may experience left-sided abdominal or flank pain that worsens when sitting, standing, or during physical activity 1. Hematuria can be visible or microscopic and is often the first sign that prompts medical attention. Women may develop pelvic congestion syndrome with symptoms of pelvic pain, painful menstruation, painful intercourse, and varicose veins in the pelvic region. Men might experience varicoceles (enlarged veins in the scrotum) and left-sided testicular pain. Some patients also report fatigue, orthostatic proteinuria (protein in urine when standing), gastrointestinal symptoms like nausea or abdominal discomfort, and orthostatic intolerance (dizziness when standing) 1.
Key Symptoms
- Postprandial epigastric pain
- Nausea/vomiting
- Loss of weight
- Flank pain
- Hematuria
- Pelvic congestion
- Pelvic pain
- Painful menstruation
- Painful intercourse
- Varicose veins in the pelvic region
- Varicoceles (enlarged veins in the scrotum)
- Left-sided testicular pain
- Fatigue
- Orthostatic proteinuria
- Gastrointestinal symptoms like nausea or abdominal discomfort
- Orthostatic intolerance
These symptoms occur because the left renal vein is compressed between the superior mesenteric artery and the aorta, causing increased pressure in the renal vein that leads to blood backing up into smaller vessels, resulting in pain and bleeding 1. Symptoms can vary widely in severity, with some patients experiencing mild discomfort while others have debilitating pain requiring intervention. The most recent and highest quality study suggests that the symptoms of nutcracker syndrome are primarily related to the compression of the left renal vein, which can cause a range of symptoms including pain, hematuria, and pelvic congestion 1.
From the Research
Symptoms of Nutcracker Syndrome
The symptoms of nutcracker syndrome include:
- Hematuria (blood in the urine) 2, 3, 4, 5, 6
- Proteinuria (excess protein in the urine) 2, 3, 4, 5, 6
- Flank pain 2, 3, 4, 5, 6
- Varicocele (enlargement of the veins in the scrotum) 2
- Orthostatic hypotension (low blood pressure when standing up) 4
- Renal dysfunction 4
- Pelvic congestion syndrome (a condition characterized by chronic pain in the pelvic area) 4
Common Symptoms
The most common symptoms of nutcracker syndrome are:
- Left flank pain (reported in 100% of patients in one study) 5
- Hematuria (reported in 47-57.6% of patients in different studies) 3, 5, 6
- Proteinuria (reported in 39.4-88% of patients in different studies) 3, 5, 6
Diagnosis and Treatment
Diagnosis of nutcracker syndrome is often made after excluding other causes, and confirmation is typically made using Doppler ultrasonography or computed tomography 3. Treatment options vary depending on the severity of symptoms and patient characteristics, and may include conservative management, open surgery, endovascular surgery, or a combination of these approaches 2, 3, 4, 5.