Pediatric Varicocele as the Presenting Sign of Nutcracker Syndrome: An Ultrasound Case Report.

BACKGROUND: Pediatric varicocele is most often recognized during adolescence; presentation at a younger age or with atypical features should prompt consideration of secondary causes. Nutcracker syndrome (NCS) is the symptomatic clinical consequence of left renal vein (LRV) compression and may produce collateral gonadal venous reflux. CASE PRESENTATION: A 10-year-old boy presented with a 6-month history of painless left scrotal swelling. Examination demonstrated a soft "bag of worms" mass that became more prominent with standing and the Valsalva maneuver. Urinalysis showed no hematuria or proteinuria. Scrotal Doppler ultrasonography demonstrated left pampiniform plexus veins measuring up to 3.31 mm with reflux. Because of the patient's young age, abdominal Doppler evaluation was extended to the renal venous circulation and demonstrated focal LRV compression between the aorta and superior mesenteric artery with marked prestenotic dilatation. The aortomesenteric angle was 8.58°, the hilar-to-compressed LRV diameter ratio was approximately 10.9:1 (5.34 mm/0.49 mm), and peak systolic velocity at the compressed segment was approximately 91.2 cm/s. The combined clinical and Doppler findings supported anterior NCS with associated left-sided varicocele. CONCLUSION: This report does not claim a novel NCS-varicocele association. Its educational value lies in demonstrating a practical Doppler pathway from an apparently isolated scrotal finding to an upstream vascular cause in a young child with normal urinalysis. Morphologic and hemodynamic ultrasound findings should be interpreted together with the clinical presentation.