Nutcracker Syndrome: Causes, Symptoms & Treatment

Nutcracker syndrome is a venous compression of the left renal vein, usually accompanied by pain symptoms and blood or protein in the urine. Treatment often takes the form of stenting. The prognosis is excellent.

What is nutcracker syndrome?

The disease group of vein compression includes various conditions symptomatically associated with compressed veins. One such condition is nutcracker syndrome. Nutcracker phenomenon is the most common vascular compression of all. The exact prevalence of the symptom complex is not known. All symptoms of the syndrome are due to jamming of the left renal vein. In most cases, the vein becomes wedged between the abdominal aorta and the superior mesenteric artery. As a consequence, the pressure gradient between the inferior vena cava and LRV increases to about three times normal. The thin venous septa rupture and hematuria occurs. Three different types of the syndrome are distinguished: besides an anterior one, medicine knows a posterior and a combined nutcracker phenomenon. Most of the cases described so far have occurred in the Far East. Often the disease manifests itself between the third and fourth decade of life. The female sex is more frequently affected by the syndrome than the male sex.

Causes

Nutcracker syndrome is favored by human anatomy and thus stems from a general disposition of the human race. Genetic predispositions or familial clustering do not appear to exist. Thus, jamming of the left renal vein between the abdominal aorta and the superior mesenteric artery is anatomically a risk for any human. Scientists believe that human evolution is to blame for this risk. Thus, the upright gait of humans has produced a lordosis or characteristic curvature of the lumbar spine. This curvature is now believed to be the actual cause of nutcracker syndrome. The condition does not appear to be related to height or related parameters. In most cases, patients are asthenic and normal-sized individuals of average height.

Symptoms, complaints, and signs

Nutcracker syndrome usually manifests as urologic or gynecologic symptoms. Urologic symptoms may include left-sided lumbar pain. Left-sided macroscopic or microscopic hematuria or proteinuria may also develop. Varicocele or varices often develop in the lower extremities. The gynecological manifestations of the syndrome are associated with the term pelvic congestion syndrome. They may manifest as abdominal pain, dysmenorrhea, aversion to coitus, dysuria, or varices in the pelvic, vulvar, or thigh areas. Emotional disturbances are also conceivable. In addition to abdominal pain, left flank pain, and left convex lordosis in the lumbar region, women with nutcracker syndrome may have left ovarian pain, severe and pain during sexual intercourse. Both women and men with the syndrome also often complain of severe back pain, headaches, or pain in the genital area. Hemorrhoids may as well be an accompanying symptom of the condition, as they are characterized by an increase in blood flow. In men, sperm production may be limited.

Diagnosis and course of the disease

Dia diagnosis for nutcracker syndrome can be made unequivocally by functional color Doppler sonography. Other diagnostic tools may include computed tomography or magnetic resonance imaging. Confirmation of a suspected diagnosis often takes place by contrast imaging of the renal vein, also known as phlebography. Pressure measurement in the renal vein or inferior vena cava may also demonstrate diagnostic qualities. The prognosis for people with nutcracker syndrome is relatively favorable. Numerous therapeutic steps are available to alleviate symptoms. Patients in the growth phase are often only observed and not treated. Their physical development may favor spontaneous remission of all symptoms. Overall, the prognosis for all patients is excellent.Affected individuals with marked symptomatology, such as severe pain or severe hematuria, rely on active surgical intervention, although prognostic predictions after intervention are excellent.

Complications

In most cases, the symptoms and compilations of nutcracker syndrome can be relatively well avoided and limited. There is always a positive course of the disease. Affected individuals suffer from severe pain due to nutcracker syndrome. Furthermore, bloody urine may also occur. Pain in the abdomen or lower abdomen can also be caused by nutcracker syndrome and lead to a significantly reduced quality of life. Similarly, severe abdominal pain and flank pain occur, which can lead primarily to an aversion to sexual intercourse. These pains not infrequently spread to the head or back and can lead to irritability of the affected person. Among other things, the refusal of sexual intercourse can also lead to disturbances in a relationship. Surgery is usually performed for nutcracker syndrome to relieve the symptoms. The installation of a stent can also reduce the discomfort. Usually, no complications occur in this process. However, in most cases, the patient’s exercise tolerance is reduced because of the procedure.

When should you see a doctor?

Nutcracker syndrome does not always cause symptoms and, accordingly, does not necessarily require treatment. Medical advice is required when the typical complaints occur. Anyone who notices blood in the urine, pain in the area of the flanks or in the testicles, as well as disturbed sperm formation, should in any case consult the doctor. Pain in the pelvis or in the area of the ovaries also requires medical clarification. The doctor will examine the patient physically and then make a diagnosis. If the diagnosis is made early, complications such as testicular and ovarian dysfunction can usually be avoided. People who already suffer from nerve disorders should immediately speak with the appropriate medical professional if the above symptoms occur. Also people with arterial complaints or malformations in the genital area belong to the risk groups and should go to the doctor in any case with mentioned complaints. This is particularly necessary if the symptoms become more severe or cannot be alleviated by stretching exercises and bed rest. Then a doctor must determine the cause and initiate therapy. In addition to the family doctor, the urologist or gynecologist as well as a neurologist are the right places to start. Accompanying physiotherapists should be included in the treatment.

Treatment and therapy

Therapy for nutcracker syndrome is not indicated in all cases. As in people going through puberty, monitoring of symptoms is more indicated in patients with only mild symptoms and minimal hematuria. Even in cases of painless and intermittent hematuria with normal blood counts, monitoring therapy is preferred for the time being. In all other cases, vascular transpositions are indicated. In the past, autotransplantation of the kidney was often considered as a treatment measure. These are open surgical procedures that show good results. However, since these procedures are associated with significant morbidity, they are now rarely used. Nowadays, nutcracker syndrome is more commonly treated with extravascular stents. In this procedure, a graft, usually made of PTFE, is placed in the circumference of the left renal vein from the confluence with the inferior vena cava to the confluence with the left gonadal adrenal vein. Stent placement can be performed openly surgically or as part of a laparoscopic procedure. An intravascular and self-deploying metal stent is most commonly chosen. This stent travels to the area of the left renal vein under local anesthesia and digital subtraction angiography guidance. The medial end of the stent is placed in the inferior vena cava.

Prospect and prognosis

Nutcracker syndrome has a favorable prognosis. The course of the disease is mostly described as positive in the literature. As soon as pain, disturbances of blood flow, or limitations of movement occur, cooperation with a physician should be sought. This ensures a quick diagnosis and leads to the initiation of necessary medical interventions.Within a short time, there is considerable relief of the symptoms. Recovery is achieved following wound healing in almost all affected persons. If medical help is not sought, an increase in complaints and health irregularities is to be expected. The same applies if an improvement of the overall situation is to be achieved via naturopathic treatments or other alternative healing methods. The possibilities of these therapeutic approaches are not sufficient to achieve a cure in this syndrome. Rather, complications are to be expected and coping with everyday life becomes increasingly difficult. For long-term freedom from symptoms, the installation of a stent is recommended in some patients. This should prevent a relapse of the disease and guarantee stable vascular activity for life. Nevertheless, it is advisable to have check-ups at regular intervals so that immediate action can be taken in the event of possible complications or changes in the organism. Especially after falls or accidents, clarification of functional activity is recommended.

Prevention

Promising preventive measures for nutcracker syndrome do not exist, since the symptom complex is favored by the natural curvature of the lumbar spine. However, targeted exercises to reduce lordosis may be able to reduce the risk for the syndrome.

Follow-up

In most cases of nutcracker syndrome, no special measures or options for aftercare are available to the affected person at all, although these are not always necessary. With proper and especially with timely treatment, there are no further complications or further discomfort. Therefore, the affected person should ideally see a doctor at the first signs and symptoms of the disease to prevent further deterioration of the symptoms. As a rule, self-healing cannot occur in nutcracker syndrome. After the procedure, which can completely relieve the symptoms of nutcracker syndrome, the affected person should have regular check-ups by a urologist. In this way, the condition of the kidneys can be permanently monitored in order to detect further complaints at an early stage. In some cases, physiotherapy measures are also necessary. In this case, the patient can perform many therapy exercises at home in order to accelerate the treatment. Further measures of an aftercare are usually no longer necessary. The nutcracker syndrome does not reduce the life expectancy of the affected person. However, the sooner a doctor is consulted for this disease, the better the further course of the disease.

What you can do yourself

Nutcracker syndrome is a nervous condition that can be treated well nowadays. The medical treatment can be supported primarily by moderate Bewegug and special stretching exercises. The physician will describe appropriate stretching exercises which, on the one hand, alleviate any nerve complaints and, on the other hand, prevent a nerve from being pinched again. Furthermore, patients should determine the cause of nutcracker syndrome. There are a wide variety of triggers, which can vary greatly. It is therefore advisable to keep a diary of complaints and note any causes in it. This is particularly advisable shortly after therapy, since a connection between the syndrome and possible triggers can usually still be established here. Drug treatment can be supplemented with natural painkillers. Teas as well as ointments and lotions that can be applied externally to the affected area have proven effective. If an unhealthy lifestyle is the cause of nutcracker syndrome, a nutritionist must be consulted. The expert can name further treatment measures and thus help to prevent the painful nerve condition from recurring. The patient should also go for regular medical check-ups to reduce the risk of complications.