Haematuria and the nutcracker syndrome

A 29-year-old female was referred to our hospital because of a 4-year history of intermittent gross haematuria. Physical examination was unremarkable. Urinalysis showed gross haematuria. The urine red blood cells are isomorphic. Cystoscopy revealed bloody urine from the left ureter. A computed tomography angiography of renal vascular revealed a compression of the left renal vein (LRV) between the abdominal aorta (AA) and the superior mesenteric artery (SMA, Figure 1). A diagnosis of nutcracker syndrome was made. The haematuria disappeared 2 weeks after an endovascular stent implantation of the LRV. Nutcracker syndrome, a rare cause of haematuria, is caused by a compression of the LRV between the AA and the SMA.1,2 Clinically, this entity can be silent or embraces a spectrum symptom, including gross or microscopic haematuria, orthostatic proteinuria, flank pain, pelvic congestion, varicocele and chronic fatigue.1,3 Because these symptoms are non-pathognomonic, the diagnosis is difficult to make using routine methods.1,3 This condition should be always considered in the workup of haematuria. Various non-invasive tests are used for the diagnosis of nutcracker syndrome, such as ultrasonography, CT imaging and magnetic resonance imaging. The most reliable method is CT angiography.1