European Spine Journal

, Volume 22, Issue 5, pp 1019–1029 | Cite as

Complaints of micturition, defecation and sexual function in cauda equina syndrome due to lumbar disk herniation: a systematic review

  • N. S. KorseEmail author
  • W. C. H. Jacobs
  • H. W. Elzevier
  • C. L. A. M. Vleggeert-Lankamp
Review Article



Cauda equina syndrome (CES) is a rare complication of lumbar disk herniation. Although micturition, defecation and/or sexual function are by definition affected, little seems to be known about long-term outcome. Aim of this study is to review current literature on outcome of micturition, defecation and sexual function in CES due to lumbar disk herniation.


A literature search was done in Pubmed, Embase and Web of Science using a sensitive search string combination. Studies were selected by predefined selection criteria and risk of bias was assessed using a Cochrane checklist adjusted for this purpose.


Fifteen studies were included. Risk of bias varied with six studies showing low risk. Mean minimal follow-up time was 17.0 months (range 3–24 months). All studies evaluated micturition and reported dysfunction at follow-up in 42.5 % (range 13.3–90.0 %). Defecation and sexual function were evaluated in eight and nine studies, respectively, and reported to be 49.6 (range 10.5–90.0 %) and 44.3 % (range 10.0–76.6 %), respectively. Only two studies assessed sexual function in all patients at follow-up.


This review offers an insight into the extent of micturition dysfunction, defecation dysfunction and sexual dysfunction (SD) in CES after decompression. Our findings show that dysfunction is extremely common, even at long-term follow-up. A condition as invalidating as CES requires proper patient information and the outcomes presented here may help in providing those data. Bias in included studies, lack of universal definitions and incomplete follow-up results qualify these data as the best we momentarily have, but still subject to improvement. Since SD seems to be severely underreported, we recommend further research to explore the extent of this problem, as well as the use of questionnaires in future clinical (prospective) studies to accomplish a more patient-based approach.


Cauda equina syndrome Lumbar disk herniation Micturition Defecation Sexual dysfunction Pelvic floor 


Conflict of interest



  1. 1.
    Mixter WJ, Barr JS (1934) Rupture of the intervertebral disk with involvement of the spinal canal. N Engl J Med 211(5):210–225CrossRefGoogle Scholar
  2. 2.
    Fraser S, Roberts L, Murphy E (2009) Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil 90(11):1964–1968. doi: 10.1016/j.apmr.2009.03.021 PubMedCrossRefGoogle Scholar
  3. 3.
    Shephard RH (1959) Diagnosis and prognosis of cauda equina syndrome produced by protrusion of lumbar disk. Br Med J 2(5164):1434–1439PubMedCrossRefGoogle Scholar
  4. 4.
    Aho AJ, Auranen A, Pesonen K (1969) Analysis of cauda equina symptoms in patients with lumbar disk prolapse. Pre-operative and follow-up clinical and cystometric studies. Acta Chir Scand 135(5):413–420PubMedGoogle Scholar
  5. 5.
    Jennett WB (1956) A study of 25 cases of compression of the cauda equina by prolapsed intervertebral disks. J Neurol Neurosurg Psychiatry 19(2):109–116PubMedCrossRefGoogle Scholar
  6. 6.
    DeLong WB, Polissar N, Neradilek B (2008) Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. J Neurosurg Spine 8(4):305–320. doi: 10.3171/spi/2008/8/4/305 PubMedCrossRefGoogle Scholar
  7. 7.
    Radcliff KE, Kepler CK, Delasotta LA, Rihn JA, Harrop JS, Hilibrand AS, Albert TJ, Vaccaro AR (2011) Current management review of thoracolumbar cord syndromes. Spine J 11(9):884–892. doi: 10.1016/j.spinee.2011.07.022 PubMedCrossRefGoogle Scholar
  8. 8.
    Spector LR, Madigan L, Rhyne A, Darden B, Kim D (2008) Cauda equina syndrome. J Am Acad Orthop Surg 16(8):471–479PubMedGoogle Scholar
  9. 9.
    Ma B, Wu H, Jia LS, Yuan W, Shi GD, Shi JG (2009) Cauda equina syndrome: a review of clinical progress. Chin Med J 122(10):1214–1222. doi: 10.3760/cma.j.issn.0366-6999.2009.10.019 PubMedGoogle Scholar
  10. 10.
    Platform-Evidence-Based-Richtlijn-Ontwikkeling (2006) Formulier III voor het beoordelen van een Cohortonderzoek. Dutch Cochrane Center. Accessed 29 March 2012
  11. 11.
    Harbord RM, Higgins JPT (2009) Meta Regression in Stata. In: Sterne JAC (ed) Meta-analysis in Stata: an updated collection from the Stata journal, 1st edn. Stata Press, College Station, pp 70–96Google Scholar
  12. 12.
    Higgins JPT, Thompson SG (2004) Controlling the risk of spurious findings from meta-regression. Stat Med 23:1663–1682PubMedCrossRefGoogle Scholar
  13. 13.
    Shapiro S (1993) Cauda equina syndrome secondary to lumbar disk herniation. Neurosurgery 32(5):743–746 discussion 746–747PubMedCrossRefGoogle Scholar
  14. 14.
    Shapiro S (2000) Medical realities of cauda equina syndrome secondary to lumbar disk herniation. Spine (Phila Pa 1976) 25(3):348–351 discussion 352CrossRefGoogle Scholar
  15. 15.
    Dhatt S, Tahasildar N, Tripathy SK, Bahadur R, Dhillon M (2011) Outcome of spinal decompression in cauda equina syndrome presenting late in developing countries: case series of 50 cases. Eur Spine J 20(12):2235–2239. doi: 10.1007/s00586-011-1840-4 PubMedCrossRefGoogle Scholar
  16. 16.
    Qureshi A, Sell P (2007) Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome. Eur Spine J 16(12):2143–2151. doi: 10.1007/s00586-007-0491-y PubMedCrossRefGoogle Scholar
  17. 17.
    Kostuik JP, Harrington I, Alexander D, Rand W, Evans D (1986) Cauda equina syndrome and lumbar disk herniation. J Bone Joint Surg Am 68(3):386–391PubMedGoogle Scholar
  18. 18.
    O’Laoire SA, Crockard HA, Thomas DG (1981) Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disk prolapse. Br Med J (Clin Res Ed) 282(6279):1852–1854CrossRefGoogle Scholar
  19. 19.
    Buchner M, Schiltenwolf M (2000) Cauda equina syndrome caused by intervertebral lumbar disk prolapse—mid-term results of 22 patients and review of the literature. Neuro Orthop 27(1–2):55–64Google Scholar
  20. 20.
    Buchner M, Schiltenwolf M (2002) Cauda equina syndrome caused by intervertebral lumbar disk prolapse: mid-term results of 22 patients and literature review. Orthopedics 25(7):727–731PubMedGoogle Scholar
  21. 21.
    Hussain SA, Gullan RW, Chitnavis BP (2003) Cauda equina syndrome: outcome and implications for management. Br J Neurosurg 17(2):164–167PubMedCrossRefGoogle Scholar
  22. 22.
    McCarthy MJH, Aylott CEW, Grevitt MP, Hegarty J (2007) Cauda equina syndrome—factors affecting long-term functional and sphincteric outcome. Spine 32(2):207–216. doi: 10.1097/01.brs.0000251750.20508.84 PubMedCrossRefGoogle Scholar
  23. 23.
    Crocker M, Fraser G, Boyd E, Wilson J, Chitnavis BP, Thomas NW (2008) The value of inter hospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study. Ann R Coll Surg Engl 90(6):513–516. doi: 10.1308/003588408x301154 PubMedCrossRefGoogle Scholar
  24. 24.
    Hellstrom P, Kortelainen P, Kontturi M (1986) Late urodynamic findings after surgery for cauda equina syndrome caused by a prolapsed lumbar intervertebral disk. J Urol 135(2):308–312PubMedGoogle Scholar
  25. 25.
    Gleave JR, MacFarlane R (1990) Prognosis for recovery of bladder function following lumbar central disk prolapse. Br J Neurosurg 4(3):205–209PubMedCrossRefGoogle Scholar
  26. 26.
    Kennedy JG, Soffe KE, McGrath A, Stephens MM, Walsh MG, McManus F (1999) Predictors of outcome in cauda equina syndrome. Eur Spine J 8(4):317–322PubMedCrossRefGoogle Scholar
  27. 27.
    Spannare BJ (1978) Prolapsed lumbar intervertebral disk with partial or total occlusion of the spinal canal. A study of 30 patients with and 28 patients without cauda equina symptoms. Acta Neurochir (Wien) 42(3–4):189–198CrossRefGoogle Scholar
  28. 28.
    Elgamri A, Sami A, Aqqad A, Hilmani S, Ibahioin K, Naja A, El Kamar A, El Azhari A (2009) Posterior migration of a lumbar disk herniation as a cause of cauda equina syndrome. J Radiol 90(6):731–733 FrenchPubMedCrossRefGoogle Scholar
  29. 29.
    Schaeffer HR (1966) Cauda equina compression resulting from massive lumbar disk extrusion. Aust N Z J Surg 35(4):300–306PubMedCrossRefGoogle Scholar
  30. 30.
    von Wild K (1990) Lumbar intervertebral disk operation in the aged. Zentralbl Neurochir 51(1):34–41Google Scholar
  31. 31.
    Akbas NB, Dalbayrak S, Kulcu DG, Yilmaz M, Yilmaz T, Naderi S (2010) Assessment of sexual dysfunction before and after surgery for lumbar disk herniation. J Neurosurg Spine 13(5):581–586. doi: 10.3171/2010.5.spine09906 PubMedCrossRefGoogle Scholar
  32. 32.
    Fairburn B, Stewart JM (1955) Lumbar disk protrusion as a surgical emergency. Lancet 269(6885):319–321PubMedCrossRefGoogle Scholar
  33. 33.
    Lafuente DJ, Andrew J, Joy A (1985) Sacral sparing with cauda equina compression from central lumbar intervertebral disk prolapse. J Neurol Neurosurg Psychiatry 48(6):579–581PubMedCrossRefGoogle Scholar
  34. 34.
    Todd NV (2005) Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg 19(4):301–306. doi: 10.1080/02688690500305324 PubMedCrossRefGoogle Scholar
  35. 35.
    Tsai CH, Chou ECL, Chou LW, Chen YJ, Chang CH, Tsou HK, Chen HT (2010) The evaluation of bladder symptoms in patients with lumbar compression disorders who have undergone decompressive surgery. Spine 35(17):E849–E854PubMedCrossRefGoogle Scholar
  36. 36.
    Jegede KA, Ndu A, Grauer JN (2010) Contemporary management of symptomatic lumbar disk herniations. Orthop Clin North Am 41(2):217–224PubMedCrossRefGoogle Scholar
  37. 37.
    Akbar A, Mahar A (2002) Lumbar disk prolapse: management and outcome analysis of 96 surgically treated patients. J Pak Med Assoc 52(2):62–65PubMedGoogle Scholar
  38. 38.
    Bartels R, deVries J (1996) Hemi-cauda equina syndrome from herniated lumbar disk: a neurosurgical emergency? Can J Neurol Sci 23(4):296–299PubMedGoogle Scholar
  39. 39.
    Choudhury AR, Taylor JC (1980) Cauda equina syndrome in lumbar disk disease. Acta Orthop Scand 51(3):493–499PubMedGoogle Scholar
  40. 40.
    Nielsen B, de Nully M, Schmidt K, Hansen RI (1980) A urodynamic study of cauda equina syndrome due to lumbar disk herniation. Urol Int 35(3):167–170PubMedCrossRefGoogle Scholar
  41. 41.
    Dinning TA, Schaeffer HR (1993) Discogenic compression of the cauda equina: a surgical emergency. Aust N Z J Surg 63(12):927–934PubMedCrossRefGoogle Scholar
  42. 42.
    Podnar S, Oblak C, Vodusek DB (2002) Sexual function in men with cauda equina lesions: a clinical and electromyographic study. J Neurol Neurosurg Psychiatry 73(6):715–720PubMedCrossRefGoogle Scholar
  43. 43.
    Podnar S (2006) Bowel dysfunction in patients with cauda equina lesions. Eur J Neurol 13(10):1112–1117. doi: 10.1111/j.1468-1331.2006.01423.x PubMedCrossRefGoogle Scholar
  44. 44.
    Podnar S, Trsinar B, Vodusek DB (2006) Bladder dysfunction in patients with cauda equina lesions. Neurourol Urodyn 25(1):23–31. doi: 10.1002/nau.20188 PubMedCrossRefGoogle Scholar
  45. 45.
    Scott PJ (1965) Bladder paralysis in cauda equina lesions from disk prolapse. J Bone Joint Surg Br 47:224–235PubMedGoogle Scholar
  46. 46.
    Mosdal C, Iversen P, Iversen-Hansen R (1979) Bladder neuropathy in lumbar disk disease. Acta Neurochir (Wien) 46(3–4):281–286CrossRefGoogle Scholar
  47. 47.
    Jalloh I, Minhas P (2007) Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J 24(1):33–34. doi: 10.1136/emj.2006.038182 PubMedCrossRefGoogle Scholar
  48. 48.
    Inui Y, Doita M, Ouchi K, Tsukuda M, Fujita N, Kurosaka M (2004) Clinical and radiologic features of lumbar spinal stenosis and disk herniation with neuropathic bladder. Spine (Phila Pa 1976) 29(8):869–873CrossRefGoogle Scholar
  49. 49.
    Olivero WC, Wang HA, Hanigan WC, Henderson JP, Tracy PT, Elwood PW, Lister JR, Lyle L (2009) Cauda equina syndrome (CES) from lumbar disk herniations. J Spinal Disord Tech 22(3):202–206. doi: 10.1097/BSD.0b013e31817baad8 PubMedCrossRefGoogle Scholar
  50. 50.
    Busse JW, Bhandari M, Schnittker JB, Reddy K, Dunlop RB (2001) Delayed presentation of cauda equina syndrome secondary to lumbar disk herniation: functional outcomes and health-related quality of life. CJEM 3(4):285–291PubMedGoogle Scholar
  51. 51.
    Geisler BP, van Dam RM, Gazelle GS, Goehler A (2009) Risk of bias in meta-analysis on erythropoietin-stimulating agents in heart failure. Heart 95(15):1278–1279. doi: 10.1136/hrt.2009.172163 author reply 1279PubMedCrossRefGoogle Scholar
  52. 52.
    Mangum K, Partna L, Vavrek D (2012) Spinal manipulation for the treatment of hypertension: a systematic qualitative literature review. J Manip Physiol Ther. doi: 10.1016/j.jmpt.2012.01.005 Google Scholar
  53. 53.
    Hartling L, Bond K, Vandermeer B, Seida J, Dryden DM, Rowe BH (2011) Applying the risk of bias tool in a systematic review of combination long-acting beta-agonists and inhaled corticosteroids for persistent asthma. PLoS ONE 6(2):e17242. doi: 10.1371/journal.pone.0017242 PubMedCrossRefGoogle Scholar
  54. 54.
    Scheiber-Nogueira MC (2009) Sexual dysfunction in cauda equina syndrome. Pelvi-Perineologie 4(3):191–195. doi: 10.1007/s11608-009-0249-6 CrossRefGoogle Scholar
  55. 55.
    Choy DS (1999) Early relief of erectile dysfunction after laser decompression of herniated lumbar disk. J Clin Laser Med Surg 17(1):25–27PubMedGoogle Scholar
  56. 56.
    Orlin JR, Klevmark B (2008) Successful disk surgery after 17 years of erectile dysfunction caused by a “silent” disk protrusion. Scand J Urol Nephrol 42(1):91–93. doi: 10.1080/00365590701428467 PubMedCrossRefGoogle Scholar
  57. 57.
    Alexander M, Rosen RC (2008) Spinal cord injuries and orgasm: a review. J Sex Marital Ther 34(4):308–324. doi: 10.1080/00926230802096341 PubMedCrossRefGoogle Scholar
  58. 58.
    Deforge D, Blackmer J, Garritty C et al (2006) Male erectile dysfunction following spinal cord injury: a systematic review. Spinal Cord 44(8):465–473PubMedCrossRefGoogle Scholar
  59. 59.
    Larsen E, Hejgaard N (1984) Sexual dysfunction after spinal cord or cauda equina lesions. Paraplegia 22(2):66–74. doi: 10.1038/sc.1984.14 PubMedCrossRefGoogle Scholar
  60. 60.
    Zabihi N, Mourtzinos A, Maher MG, Raz S, Rodriguez LV (2008) The effects of bilateral caudal epidural S2–4 neuromodulation on female sexual function. Int Urogynecol J Pelvic Floor Dysfunct 19(5):697–700. doi: 10.1007/s00192-007-0504-8 PubMedCrossRefGoogle Scholar
  61. 61.
    Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP (2000) Cauda equina syndrome secondary to lumbar disk herniation —A meta-analysis of surgical outcomes. Spine 25(12):1515–1522. doi: 10.1097/00007632-200006150-00010 PubMedCrossRefGoogle Scholar
  62. 62.
    Gleave JRW, Macfarlane R (2002) Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg 16(4):325–328. doi: 10.1080/0268869021000032887 PubMedCrossRefGoogle Scholar
  63. 63.
    Nascone JW, Lauerman WC, Wiesel SW (1999) Cauda equina syndrome: is it a surgical emergency? University Pennsylvania Orthop J 12:73–76Google Scholar
  64. 64.
    Gardner A, Gardner E, Morley T (2011) Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J 20(5):690–697. doi: 10.1007/s00586-010-1668-3 PubMedCrossRefGoogle Scholar
  65. 65.
    Tandon PN, Sankaran B (1967) Cauda equina syndrome due to lumbar disk prolapse. Indian J Orthop 1:112–119Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • N. S. Korse
    • 1
    Email author
  • W. C. H. Jacobs
    • 1
  • H. W. Elzevier
    • 2
  • C. L. A. M. Vleggeert-Lankamp
    • 1
  1. 1.Department of NeurosurgeryLeiden University Medical Center (LUMC)LeidenThe Netherlands
  2. 2.Department of UrologyLeiden University Medical Center (LUMC)LeidenThe Netherlands

Personalised recommendations