From the Guidelines
Nutcracker syndrome presents with a variety of clinical manifestations primarily related to compression of the left renal vein between the superior mesenteric artery and the aorta, including hematuria, left flank pain, pelvic congestion symptoms, and varicocele. The most common symptom is hematuria, which can range from microscopic to gross bleeding, resulting from rupture of thin-walled varices into the collecting system due to increased venous pressure 1. Patients often experience left flank pain or abdominal pain that may worsen when sitting, standing, or during physical activity. Pelvic congestion symptoms are common, particularly in women, manifesting as dysmenorrhea, dyspareunia, and pelvic pain due to gonadal vein reflux. Men may experience varicocele, typically left-sided, and associated testicular pain or discomfort. Some key clinical manifestations of nutcracker syndrome include:
- Hematuria
- Left flank pain or abdominal pain
- Pelvic congestion symptoms, such as dysmenorrhea, dyspareunia, and pelvic pain
- Varicocele, typically left-sided, and associated testicular pain or discomfort
- Orthostatic proteinuria
- Fatigue, headaches, and autonomic dysfunction from chronic venous hypertension
- Gastrointestinal symptoms like abdominal distension, nausea, and altered bowel habits due to mesenteric venous congestion. Diagnosis typically requires imaging studies like Doppler ultrasound, CT angiography, or MR venography to visualize the vascular compression and measure pressure gradients across the narrowed segment 1.
From the Research
Clinical Manifestations of Nutcracker Syndrome
The clinical manifestations of Nutcracker syndrome (NCS) include:
- Hematuria, which is often microscopic 2, 3, 4, 5, 6
- Proteinuria, including orthostatic proteinuria 2, 3, 4, 5, 6
- Flank or pelvic pain, which can worsen with standing and increased lumbar lordosis 2, 3, 4, 5, 6
- Varicocele, particularly in male patients 2, 3, 4, 5, 6
- Orthostatic hypotension and fatigue 5, 6
- Abdominal pain 6
- Dyspareunia and other gynecological symptoms 6
- Varicose veins in the pelvis, buttocks, or upper thighs 6
Diagnostic Challenges
Diagnosis of NCS can be challenging due to variations in normal anatomy and the need for a combination of clinical findings and imaging studies to establish the diagnosis 2, 3, 5, 6. Imaging studies such as Doppler ultrasonography, computed tomography, magnetic resonance imaging, and intravascular ultrasound (IVUS) may be used to aid in diagnosis 3, 5.
Treatment Options
Treatment options for NCS range from conservative management to surgical interventions, including endovascular stenting, open surgery, and laparoscopic surgery 2, 3, 4, 5, 6. The choice of treatment depends on the severity of symptoms and the presence of complications such as renal dysfunction or venous thrombosis 3, 5.