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  Thursday, 06 January 2022
  3 Replies
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25 year-old woman

I have chronic abdominal/pelvic pain. I experience dull pain daily and sharper pain at times, it wraps around my low back and extends to my bladder. I do have bladder pain as well.

Over the past 6 months I have had 3 urine tests come back with microscopic hematuria (increasing over time, most recently 25 RBC). Cultures were done all three times, no infection present.
I also had general blood work for kidneys recently:
General Chemistry
Sodium 140 mmol/L
Potassium 4.1 mmol/L
Creatinine 76 umol/L
Glomerular Filtration Rate (eGFR) 95

I was misdiagnosed with endometriosis and had laparoscopy in May. Upon surgery, scar tissue and adhesions were removed and so was my appendix, nothing else noted.

I have had kidney ultrasounds and no presence of stones, cysts, or masses. I had an unremarkable cystoscopy ~1 year ago.

Are there kidney conditions that may be confused for gynecological ones? Kidney issues (stones) run in my family, but I've never had one. I've read about nutcracker syndrome and it seems to encompass a lot of my symptoms but I don't know how to be tested for it.

The nutcracker syndrome is compression of a renal vein leading to back pressure inside the kidney that presents with pain and hematuria. This can be very similar and in fact may be identical to many presentations of the so-called loin pain haematuria syndrome which is just as it sounds - a syndrome where patient experience pain accompanied by haematuria that is not explained by other known pathology. However, in general, both of these entities are largely a diagnosis of exclusion. In particular, loin pain haematuria syndrome, if not due to a nutcracker phenomenon, is often diagnosed clinically rather than by any diagnostic testing. In some cases, magnetic resonance and geography can be helpful.

Please see the attached case report and let me know if this reflects your experience in terms of symptoms:

Nutcracker Syndrome

Dr. Jordan Weinstein
2 years ago
Hello and thank you for your helpful response!

This does sound like me in a lot of ways. I have never had visible blood in the urine, just microscopic, but otherwise yes. I also have all the symptoms they list of pelvic congestion (which are also symptoms of endometriosis which it is now confirmed that I do NOT have).

I had a pelvic MRI over a year ago to look at ovaries/uterus/rectum, but the report doesn't mention my kidneys and I don't think they were looked at. I have a nephrology referral that I'm waiting on - is it likely an MRI would be needed to see if it's nutcracker or (if not) LPHS?
Jordan Weinstein selected the reply #2606 as the answer for this post — 2 years ago
Jordan Weinstein revoked the reply #2606 as the answer for this post — 2 years ago
Yes, you could have an MRI as part of the work-up but if the MRI is negative, you could still meet criteria for LPHS and the treatment (which is controversial) could be used for either condition. That said, it would be preferred to know what you dealing with. ACE inhibition and ARBs have been used with some effect for LPHS. Auto-transplantation has been used for LPHS as well as nutcracker but is highly controversial. Stenting would seem to be more logical when nutcracker is proven.

Dr. Jordan Weinstein
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