Beyond venous dilatation: Nutcracker syndrome and Its Unique Hemodynamic Signature in Adolescent Varicocele.

PURPOSE: This study evaluates the association between Nutcracker Syndrome (NCS) and adolescent varicocele, focusing on hemodynamic parameters, symptom patterns, and diagnostic thresholds to optimize clinical management. METHODS: In this prospective study, 56 adolescents (mean age 14.9 ± 2.1 years) with Grade II-III varicocele underwent standardized Doppler ultrasonography to assess pampiniform plexus diameters, SMA-Aorta angles, and renal vein dynamics. NCS was defined as a standing SMA-Aorta angle < 30°. Groups were stratified by NCS status and pampiniform plexus diameter (≥ 2.8 mm vs. <2.8 mm). Symptom profiles (pain, palpable mass) and hemodynamic differences were analyzed (Tables 2 and 3). RESULTS: NCS prevalence was 71.4%. NCS(+) patients had lower BMI (p = 0.018), growth percentiles (p = 0.003), and narrower SMA-Aorta angles (standing: 16.9° vs. 26.6°, p < 0.001). Pampiniform plexus diameters were larger in NCS(+) cases (resting: 3.0 vs. 2.2 mm, p < 0.001). When the groups were evaluated in terms of isolated pain, no difference was found between them (p = 1.000), while NCS(-) patients had higher pain-mass combination scores (p = 0.012). When cases with pampiniform plexus diameter ≥ 2.8 mm were compared, significant associations were demonstrated: larger Valsalva diameters (4.50 vs. 3.01 mm, p < 0.001), narrower SMA-Aorta angles (standing: 17.3° vs. 21.4°, p = 0.008), and lower BMI percentile values (p = 0.008) were observed. CONCLUSION: NCS is prevalent in adolescent varicocele and linked to distinct hemodynamic and anthropometric profiles. Key findings include: Symptom paradox: NCS(−) patients reported more pain-mass combinations (p = 0.012). Diagnostic thresholds: Pampiniform diameter ≥ 2.8 mm and standing SMA-Aorta angle < 25° are critical markers. Routine postural Doppler screening is recommended for adolescents with varicocele, especially those with low BMI.