Neurology Case Challenge: A Man With Buttocks Pain, Bladder and Bowel Incontinence

Xuan Kang, MD


July 21, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 70-year-old man who underwent radiation therapy for stage I prostate cancer 8 years ago presents with a 2-year history of progressive lower-extremity pain and muscle weakness. His symptoms started with severe midline lower back pain, urinary incontinence, and allodynia in the buttocks. One month later, shooting pain developed down the left leg into the left foot. Two months later, he had complete loss of sensation up to his thigh. Six months later, he had muscle atrophy below his left knee, with weakness both proximally and distally, and he needed a crutch to walk. At that time, he noticed similar symptoms in his right leg.

One year later, he was unable to sit up without support. In addition, he had a 50-lb (22.68-kg) unintentional weight loss, continued severe leg pain below both knees, and complete bowel and bladder incontinence requiring adult diapers.

He reports no symptoms above his waist and no difficulty in swallowing or breathing. A urologic evaluation ruled out recurrent prostate cancer.

His past medical history includes radiation-induced cystitis that required stent placement. His family history is pertinent for stroke in his mother but no other neurologic conditions. He has a 10 pack-year history of smoking; he quit 40 years ago. He drinks one glass of wine per day and does not use illicit drugs.


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