Management of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has been
central to urology for many years.The urologic community has increasingly come
to realize that most of the men with LUTS do not have prostate enlargement and
do not need their prostates debulked surgically.
Of all the factors that have
emerged to alter the trends associated with management of LUTS and BPH, none
has had more impact than the advent of medical therapy Drugs for Kidney Disease . The selective, long-acting, α1-blocking agents terazosin, doxazosin, and tamsulosin have become most
popular because of their specificity in the urinary tract, reduced side
effects, and simplicity of dosage. In addition, finasteride, a 5-α-reductase
inhibitor, was found to be effective in men with prostates of ≥40 g.
Furthermore, the larger the prostate at baseline, the greater the efficacy of
finasteride on symptom relief and flow rate improvement. In addition to medical
therapy, an array of device therapies has emerged in the management of LUTS and
BPH. Laser prostatectomy is the oldest of the device therapies and includes
transurethral vaporization of the prostate (VLAP), transurethral evaporation of
the prostate (TUEP), and transurethral interstitial laser prostatectomy (TILP).
Studies report beneficial outcomes approaching those achieved with
transurethral resection of the prostate (TURP) with less morbidity and a
shorter hospital stay. Common diseases contribute the most to national
healthcare expenditures. The management of LUTS and BPH are such disorders and
result in the expenditure of vast healthcare resources worldwide. The surgical
strategies have an established record of outcomes documenting their potential
for symptom relief and the avoidance of future complications. Medical and
device therapies, although currently promising and attractive, therefore must
prove comparable durability.
Nutcracker syndrome is caused by compression of the left renal vein
between the aorta and the superior mesenteric artery where it passes in the
fork formed at the bifurcation of these arteries. The phenomenon results in
left renal venous hypertension.
The syndrome is manifested by
left flank and abdominal pain, with or without unilateral haematuria. Other
common presentation is as ‘pelvic congestion syndrome’ characterized by
symptoms of dysmenorrhea, dyspareunia, post-coital ache, lower abdominal pain,
dysuria, pelvic, vulvar, gluteal or thigh varices and emotional disturbances.
Likewise compression of the left renal vein can cause left renal-to-gonadal
vein reflux resulting in lower limb varices and varicoceles in males.
Its diagnosis is based on
history and physical examination, basic lab tests to exclude other causes of
haematuria, cystoscopy and ureteroscopy to confirm unilateral haematuria and
exclude other causes of this sinister symptom. Sequence of imaging has more or
less been rationalised to USS with Doppler studies, CT or MR angiography and
finally phlebography with renal vein and IVC manometery to confirm the
diagnosis.
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