Cauda Equina Syndrome (CES) is a rare but serious neurologic condition in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. CES is a clinical entity consisting of low back ache, bilateral leg pain with motor and sensory deficits, genitourinary dysfunction, saddle anaesthesia and faecal incontinence. We present three  cases in which the diagnosis of CES was missed  and led to  permanent neurological dysfunction and litigation.

Case No.1 
A 55 year old man presented to a  busy urologist with complains of poor stream and straining to pass urine of one week duration , he also reported loss of desire to void along with constipation. After a rapid preliminary examination he was started on 8 mg of  Silodosin and asked to came back with an USG KUB, uroflowmetry and urine analysis after 5 days.Two days later  patient presented to the emergency with painless retention of urine with vague back ache. After catherisation, 1 litre of urine was drained , USG KUB revealed a prostate of 35 gm with median lobe and a normal PSA. With a diagnosis of BPH with retention of urine he underwent  a TURP. On second post op day at time of discharge patient noticed weakness in lower limbs , a neurological examination done revealed decreased power in the lower limbs, saddle anaesthesia and decreased anal tone and absence of bulbo-cavernous reflex. Emergency MRI showed central disc extrusion at L5-S1 with compression on cauda equina. With a confirmed  diagnosis of Cauda equina syndrome he underwent emergency discectomy and laminectomy. Post operative  urodynamic at 3 months confirmed the diagnosis of atonic bladder and patient is presently on CIC. The urologist was sued for medical negligence and is still fighting it out in consumer court.
Case No.2
A 70 year old man , a known case of Lumbar canal stenosis (operated 5 years ago) presented with obstructive lower urinary tract symptoms of increasing severity since last one year to a urologist . He was diagnosed as a case of BPH grade 1 and started on Tamsulosin 0.4 mg. Despite three months of Tamsulosin he continued to have an obstructed uroflow with high post void residue. He underwent a TURP without a preoperative urodynamics. He was unable to void post-opertaively after trial without catheter(TWOC) and was subsequently put on intermittent catherisation. A urodynamic done 2 months later confirmed the diagnosis of atonic bladder.
Case No.3
A 35 year old female presented to emergency with retention of urine and  acute low backache of 2 days duration associated with spotting  per vagina. After Catherisation in the emergency the urology  resident noticed a mass per vagina. Trans-vaginal ultrasound confirmed the diagnosis of a  1cm prolapsed sub mucosal fibroid. She underwent Hysteroscopic resection of the fibroid. Post -operatively patient had retention of urine and failed multiple attempts of  TWOC.  Urodynamic study was suggestive of atonic bladder. MRI showed central disc extrusion at L4-L5 with compression on cauda equina. With a confirmed  diagnosis of Cauda equina syndrome she underwent  discectomy and laminectomy. At 3 months postoperative she is still using intermittent catherisation.

Three  cases in which   Cauda Equina Syndrome was  misdiagnosed . In the first and second case Cauda Equina Syndrome was misdiagnosed as BPH for which TURP was done. Delayed diagnosis resulted in permanent neuro-vesical dysfunction and litigation. The third case was very unusual wherein retention of urine was suspected to be as a result of a prolapsed small fibroid for which the patient underwent unnecessary hysteroscopic surgery.

CES is a serious condition which if not managed expeditiously leaves many patients with longterm neurological deficits. Although classical presentation of CES is with bilateral radiculopathy with  sensory/motor loss in lower limbs , loss of perianal sensations and urinary disturbances.Sometimes urinary symptoms may be the only presentation with vague back ache
Two categories of CES, CES-I (incomplete) and CES-R (retention) have been described based on the distinction if CES is complete or incomplete in relation to urinary function and saddle sensation. 
The incomplete CES (CESI) patient has objective evidence of CES but retains voluntary control of micturition  There is overwhelming evidence that good outcomes will be achieved in most patients who have incomplete lesions (CES-I) at the time of decompressive surgery.CES-R is avoided  and there will be no longterm bladder, bowel or sexual dysfunction.
There is, therefore, a window of opportunity during which the diagnosis may be made and successful treatment given. By the time the patient presents with urinary retention and absolute constipation, nerve function has reached a critical point, and within 48 hours it will be irreversibly impaired. It is of utmost importance to recognise and treat potential CES at the earliest possible opportunity and prevent CES-R. 

It may not be second nature for a urological surgeon to do a neurological examination in a patient with lower tract urinary symptoms, but in fact it takes just a few minutes to perform a focused neurological examination. The neurological examination should include examination for  ‘saddle anaesthesia’, Anal tone and  bulbocavernosus reflex.
In the first and second case the urologist landed himself in a big soup just because he  failed to perform a digital rectal examination and as a result missed the findings of lax anal tone, absent BCR and saddle anaesthesia and  missed the diagnosis of CES and ended up doing a TURP on these patients and missed the window of opportunity to reverse the nerve damage.

In the third case the diagnosis of CES was missed and patient underwent an unnecessary hysteroscopic surgery based on the presence of a prolapsed fibroid ignoring the acute back ache of the patient.Had the physician had an awareness about this condition probably neurological-vesical dysfunction could have been reversed.

CES may present as urinary symptoms and masquerade as a case of BPH especially in the elderly age group. An awareness of this condition with a practise of focused neurological examination may help to diagnose this condition and prevent permanent and serious neurological disability and medical litigation.