Features consistent with pelvic congestion syndrome, which in this case is caused by compression of the left renal vein by SMA (known as the nutcracker phenomenon). As the patient presented with persistent microscopic hematuria as associated symptoms, this is referred to as nutcracker syndrome. This syndrome can lead to renal venous hypertension, resulting in the rupture of thin-walled veins into the collecting system with resultant hematuria.

The common clinical manifestations are left flank pain, hematuria, pelvic pain and gonadal varies.

Imaging findings of multiple dilated, tortuous para uterine veins with a width >4 mm or an ovarian vein diameter >8 mm are considered measurements to suggest this diagnosis.

In this case, the possible collateral pathway is via the left ovarian vein, down to the left para-uterine veins, right para-uterine veins, right ovarian vein then towards the inferior vena cava.

As the patient is symptomatic (hematuria), surgical treatment may be necessary to relieve the pain as well as to prevent renal vein thrombosis the known complication of nutcracker syndrome.

Identifying the pelvic congestion/shunting syndrome as part of the review area for female patients presented with hematuria (enlarged uterine veins in females) is crucial to look for the possibility of nutcracker phenomenon (which is a common finding even in asymptomatic patients). This can avoid further unnecessary investigation such as cystoscopy or ureteroscopy.