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nerve pain, high psa, urine test clear
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nerve pain, high psa, urine test clear

I have been having nerve pain in my shoulders, arms, elbows, and back, accompanied by muscle spasms (twitches) that are not painful, but occur all over my body - mainly calves and upper arms, buttocks, and thighs.  I have had shakiness in hands and arms at times - feels like I haven't eaten in a day.  This has been going on six months, and came on suddenly with leg weakness that cleared up in a few weeks.  I have had two MRI's (head and cervical spine) both clear.  I have had a clear EMG as well.  Dr. was looking for MS, but does not think I have it.  I am presently being treated with cymbalta, and Dr. thinks it is a post viral syndrome causing nerve pain, even though I didn't have any sickness last year.  I have been very calm with that diagnosis.  Both brother and sister-in-law are Neurologists as well, and while confused by symptoms as well, they agree with my Neuro. on course of treatment.  He says to wait it out, could take a year or more.  I have not seen any increase in symptoms, but they persist.  Cymbalta has helped greatly with the pain.  I only have slight pain in shoulders and elbows at times.  

Since being on cymbalta (but not exactly when I started it), I have started experiencing pain after urination, discomfort with getting an erection, and pain at ejaculation.  I also have dribbling after urination, and feel like I don't completely clean out.  Neuro Dr. sent me to a urologist, and I just learned today my psa is a little high for a 45 year old, first time it has been high (I get it checked every year).  My urine test was clear, however.  He is giving me an antibiotic and will retest in four to five weeks.  This has me concerned.  He did an ultrasound of my bladder, and it looked like it was emptying ok.

Question:  Can Cymbalta cause these urinary symptoms? high psa?  With a clear urine test, along with other symptoms, what are the chances of prostate cancer?  PSA last fall was normal.  Can prostate cancer cause all these other arm/ shoulder pain and muscle twitches, and other symptoms?  Any other thoughts?

Question:  Can a nerve condition cause these urinary issues?  Prostate Cancer - same question.

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Hi there. I read the details of your symptoms and would like to think of two possibilities. One is of an advanced prostate cancer with bony metastasis possibly vertebral spine in your case. This could mimic a bulging disc or bony spur causing compressive neuropathy and possibly myelopathy. This could cause these multiple symptoms in arms and legs including the painful muscle spasms. An MRI spine would help in diagnosis. The other possibility is of MS. MS is a chronic demyelinating disorder where the disease phase is characterized by active phase and remissions. It has multiple symptoms and signs and is a diagnosis of exclusion. The symptoms of multiple sclerosis are loss of balance, muscle spasms, numbness in any area, problems with walking and coordination, tremors in one or more arms and legs. Bowel and bladder symptoms include frequency of micturition, urine leakage, eye symptoms like double vision uncontrollable rapid eye movements, facial pain, painful muscle spasms, tingling, burning in arms or legs, depression, dizziness, hearing loss, fatigue etc. The treatment is essentially limited to symptomatic therapy so the course of action would not change much whether MS has been diagnosed or not. Apart from clinical neurological examination, MRI shows MS as paler areas of demyelination, two different episodes of demyelination separated by one month in at least two different brain locations. Spinal tap is done and CSF electrophoresis reveals oligoclonal bands suggestive of immune activity, which is suggestive but not diagnostic of MS. Demyelinating neurons, transmit nerve signals slower than non-demyelinated ones and can be detected with EP tests. These are visual evoked potentials, brain stem auditory evoked response, and somatosensory evoked potential. Slower nerve responses in any one of these is not confirmatory of MS but can be used to complement diagnosis along with a neurological examination, medical history and an MRI in addition, a spinal tap. Therefore, it would be prudent to consult your neurologist with these concerns. Hope this helps. Take care.

Dr. Sharma,

Thank you very much for your thoughts.  
I have further questions, if that is ok.  A few more things:  I have a low B-12 count for several years (I get shots) and I am vitamin D deficient as of my last physical last year, so I take a supplement for that. My Neurological Symptoms came on with twitching in my forearms several times in mid December, but mainly all at once on January 5th, about two weeks later. I got up from my desk, and had weak legs (felt like ankle weights) and pain in both shoulders down to elbows, which felt like tendonitis.  Leg weakness subsided over the next week, but other symptoms increased, then leveled off at times, very extreme at times (nauseating constant pain)  My Neurologist has given me all the physical exams three times over the six months, which are normal, and my two MRI's (with contrast) of the cervical spine and brain were normal.  The neck did show one slight bulging disk, but he said it would not be causing my symptoms.  My neurological symptoms are unilateral - exactly the same in same spots on both arms (shoulder pain, upper arm pain, elbow pain, and upper back pain -shoulder blades out to arms mainly, muscle twitches.)  The pain is only in upper body, mainly both upper arms (always back of upper arms) and outer shoulders). I have had no neck pain at all.  I have had no true painful spasms, only twitches (short burst from specific spots) - and they occur everywhere - both legs equally in calves (often at the same time in both), thighs, Buttocks, abdomen, etc.  I cannot see a difference in pain from one arm to the other - it happens in both.  I notice twitches more in both calves and both shoulders/upper arms than other places.  I have had no balance problems, nor have I had foot drop or hand/finger coordination issues. While I have had double vision (progressive over the last two years, stronger this year, my eye doctor (in May) saw no signs of MS in exam and MRI reading.  I have only had slight numbness once on back of my neck and top of my head, but I was extremely stressed and tense before seeing neurological doctor.  I have had burning, (more on right side than left), and shaky hands (pretty much both hands at the same time).  I have had some ringing in ears at times.  Twice I had extreme chest muscle pain/burning that lasted hours.  I was concerned about MS and cancer.  My doctor said that the blood work he did said that it was not cancer, considering the levels he checked of two or three things.  The infectious disease (virus) doctor said the same thing... of course, neither may have been thinking about the prostate.

In all my blood work with Neurologist, who tested me for every crazy virus out there it seems, the only thing that came back high was Epstein Barr virus VCA =  2.30 (about twice the level for infection), and Epstein Barr virus EBNA = 4.79 (about four times the infected level).

Because this is so unilateral, and tests were all clear, the Neurologist is thinking Post Viral - and it has gotten into my nervous system.  He sent me to a Virus doctor.  Virus doctor said his thoughts were still neurological and sent me back (this was before cervical spine MRI, so he was thinking MS.  He kept asking why I hadn't gotten a cervical spine MRI).  The only test I have not had now is the spinal tap, which my Doctor said he would do, but did not think it was necessary - I am not presenting for MS in his mind.  It was what he was really looking for as well.  I trusted his opinion.
I only really started getting the urological symptoms in the last two months, about the time I went on Cymbalta for the nerve pain; thus my questions about the medicine and urological symptoms.  I won't rehash those symptoms - they are above in earlier post.  
New information:  My PSA in August 2010 was 0.9, and has never been high in past testing, which has occurred every year for the last five.  I have had digital exams as well, one even in January from my primary physician.  My PSA in June 2011 (just 10 months later) is 3.88, over four times as high.  The Urologist knows all of my neurological symptoms as well.  He called with the PSA results, put me on a strong antibiotic, and wants to recheck in 4 to 6 weeks.  I am sure he is concerned about cancer as well, but hopeful for a strong infection.  
Dr. Sharma, your thoughts on prostate cancer were my main concern, considering the PSA.  He did a digital exam, and said the prostate felt normal.  
1.  If I had prostate cancer, in the short time between August (with a good PSA test) and December when my neurological symptoms started, could a prostate cancer not show up in PSA blood work or digital exam, yet be advanced enough to cause tumor growth on spine large enough to pressure the nerves enough to cause all the other symptoms?  
2.  Wouldn't the effects on my arms show up as a pinched nerve or growth in the cervical spine MRI?  would leg twitches, buttocks, etc. be cause by a problem or tumor with the lower spine and not the neck?  I have read and my Neurologists says that something in the neck or back would not affect both legs at the same time, or arms... All my symptoms upper and lower, seem to happen in the same timeframe.  
3.  I have been very stressed, I have been eating better, cut out most sweets, etc.  I have lost about 10 pounds since this started.  My weight has leveled off at 160, which is my target range for 5'-8".  Would prostate cancer cause weight loss?  It has not been dramatic loss but consistent over the last four months.  I have weighed the same for the last month.
4.  Aren't most prostate cancers slower growing, thus detected earlier with PSA and digital exams?  What timeframe would there be for something like this to advance to the point it has spread to the bones?
5.  Should I go ahead with a spinal tap, or is it a waste of time at this point?
6.  Can a prostate infection spread into other areas that could affect the nerves, like a Post viral syndrome?  Neurologist had said I could have carried a virus for years, and my immune system got low enough for it to flare up.  I really didn't have any strong sicknesses last year.

Again, thank you so much for your thoughts Dr. Sharma.  It is difficult to wait 4 weeks for every appointment, and I want to know ahead of time if I need to pressure the Urologist to move faster, possibly with a prostate biopsy.  He is doing the prudent thing I assume, seeing if the antibiotic works....but I hate to let this drag out if it turns out to be cancer and it is advancing to the bones, especially since it has been going on since January.

I apologize for the length of this post.  I am not an alarmist, but I am very analytical.

Follow up:
I had a prostate biopsy (12 cores) that showed no sign of cancer.  Follow up PSA four months later was still 3.55.  Arm, shoulder, elbow pain persist, but no further neurological changes. Cymbalta controls the pain. Neurologist does not think it is MS or Parkinson's.  He seems confident.  Urologist can't explain PSA increase in one year, but will do follow up PSA in six months.  
Question:  since I do not have advanced prostate cancer or MS diagnosis, are there any other posibilities? Urologist said my prostate was slightly enlarged.  Can something like CFS or fybromyalgia cause prostate PSA to rise?
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