隱藏於精索靜脈曲張之胡桃鉗症候群：病例報告及文獻探討

何岩¹、鍾卓興¹

臺北市立萬芳醫院-委託財團法人臺北醫學大學辦理 泌尿科¹

Nutcracker Syndrome Concealed as Varicocele: A Clinical Report and Literature Review

Yen Ho¹, Cho-Hsing Chung¹

Department of Urology, Taipei Municipal Wan Fang Hospital¹

Introduction: Nutcracker syndrome, characterized by the compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA), is known to manifest with a variety of clinical symptoms. While hematuria, pelvic pain, and back pain are more frequently reported, the identification of varicocele as a clinical manifestation remains a rare occurrence. In order to avert potential complications, including the onset of chronic kidney disease, renal vein thrombosis, or the formation of collateral veins, a prompt and accurate diagnosis followed by timely intervention becomes paramount. In this case report, we present a unique case in which nutcracker syndrome was incidentally discovered in a young male patient, with varicocele as a notable clinical sign.

Case Presentation: A 25-year-old male with no underlying medical conditions presented with a gradual onset of bilateral testicular pain over a three-year period, with the left side experiencing more pronounced discomfort. Notably, his pain intensified during prolonged standing and when carrying heavy objects but alleviated when he assumed a seated position. The patient did not report any symptoms related to sexual dysfunction or urinary issues. As his pain progressively intensified, he sought medical evaluation at our Outpatient Department. Clinical examination in the outpatient setting revealed a Grade 3 varicocele on the left side and a Grade 2 varicocele on the right side. Subsequently, the patient underwent bilateral varicocelectomy, which proceeded without any acute complications. Postoperatively, the patient did not report any specific abdominal pain, and follow-up assessments indicated a clean wound without any signs of discharge. However, due to residual groin discomforts persisting after the surgery, a computed tomography (CT) scan was performed approximately ten days postoperatively. The CT scan revealed the compression of the left renal vein by the SMA trunk, with an acute angle measuring up to 11.82 degrees from the SMA to the aorta. Given the impression of nutcracker syndrome, the patient was subsequently referred to the cardiovascular surgery department for further evaluation and management.

Conclusion: Nutcracker syndrome, with its diverse spectrum of presenting symptoms, represents an infrequent cause of varicocele in pediatric patients. The key to achieving a timely diagnosis lies in maintaining a high degree of clinical suspicion, employing a comprehensive approach to differential diagnosis, and utilizing appropriate imaging modalities. This case underscores the importance of considering nutcracker syndrome as a potential etiology in cases of varicocele, even in young adult patients without significant underlying medical conditions.