Occasionally, patients with urological disease present with associated back pain. In some cases this may be the very .rst symptom of urological disease and it may be so severe that the patient may present acutely to the emergency department. In broad terms, there are two broad categories of disease that may present with back pain and urological symptoms: neurological conditions, and malignant conditions of urological or nonurological origin.

Neurological Disease

Patients with neurological disease may present with both back pain and disturbed lower urinary tract, disturbed bowel, and dis- turbed sexual function. Such conditions include spinal cord and cauda equina tumours and prolapsed intervertebral discs. In all of these conditions back pain is the most common early presenting symptom. It is usual gradual in onset and progresses slowly, but relentlessly. Associated symptoms suggestive of a neurological cause for the pain include pins and needles in the hands or feet, weakness in the arms (cervical cord) or legs (lumbosacral spine), urinary symptoms such as hesitancy and a poor urinary .ow, constipation, loss of erections and seemingly bizarre symptoms such as loss of sensation of orgasm or absent ejaculation. From time to time the patient may present in urinary retention. It is all too easy to assume that this is due to prostatic obstruction if a focused neurological history is not sought and a focused neurological examination is not performed.

Malignant Disease

Malignant tumours may metastasize to the vertebral column, where they may compress the spinal cord (spinal cord compression) or the nerve roots that comprise the cauda equina. Examples include urological malignancies such as prostate cancer, and nonurological malignancies such as lung cancer. In so doing they may cause both back pain and disturbed urinary, bowel, and sexual function. The pain of vertebral metastases may be localised to the area of the involved vertebra, but may also involve adjacent spinal nerve roots, causing radicular pain. Interscapular pain that wakes the patient at night is characteristic of a metastatic deposit in the thoracic spine.

The physical sign of spinal cord compression is a sensory level, but this tends to occur late in the day in the course of the condition. Remember, however, that a normal neurological examination does not exclude a diagnosis of cord compression. If, on the basis of the patient’s symptoms, you suspect cord compression, arrange for a magnetic resonance imaging (MRI) scan without delay.

Malignant in.ltration of retroperitoneal lymph nodes by, for example, testicular cancers or lymphoma can also cause back pain. As a general rule, if a patient presents with bizarre symptoms that are dif.cult to explain, consider the possibility of a neurological cause.