The diagnosis of priapism is usually obvious from the history and examination of the erect, tender penis (in low-flow pri-apism). Characteristically the corpora cavernosa are rigid and the glans is flaccid. Examine the abdomen for evidence of malignant disease and perform a digital rectal examination to examine the prostate and check anal tone.
BACK PAIN AND UROLOGICAL SYMPTOMS
Occasionally, patients with urological disease present with associated back pain. In some cases this may be the very first 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 nonuro-logical origin.
Patients with neurological disease may present with both back pain and disturbed lower urinary tract, disturbed bowel, and dis-
1. PRESENTING SYMPTOMS OF UROLOGICAL EMERGENCIES 7
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 flow, 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 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. Inter-scapular pain that wakes the patient at night is characteristic of a metastatic deposit in the thoracic spine.