Presentation
Right sided chronic epididymitis and left varicocele.
Patient Data
Dilated, tortuous, vascular structures (varices) are visualized within the bilateral pampiniform plexus (left>>>right), measuring up to 2.9 mm on the left and 1.5 mm on the right in diameter. The discordance in the variceal diameters automatically prompts an evaluation of the proximal main renal veins.
The left main renal vein junction between the ostium and the abdominal aorta appears partially focally tapered (3.1 mm in diameter) with resultant uniform engorgement of its medial and distal portions measuring up to 10 mm in diameter.
The superior mesenteric artery to abdominal aortic angle is acutely reduced as well (14.8°). The testicular volumes appear normal. The right epididymis (images not shown) appears edematous and hyperemic, consistent with unilateral chronic/recurrent epididymitis.
Case Discussion
Proximal main renal vein entrapment by the superior mesenteric artery (SMA) and the abdominal aorta may result into several conditions one of which is scrotal varicoceles that mainly affects the left hemi-scrotal venous supply.
The nutcracker phenomenon/syndrome (NCP/S) is most common in males under their 3rd decade of life. Whenever an extensively (grade III-IV) left sided scrotal varices is chanced upon, the proximal main renal vein should routinely be interrogated. Normal SMA-abdominal aorta angle ranges between 25° to 60° with a mean of 45° 1. In this presentation, the angle was 14.8°
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