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Solitary Rectal Ulcer Syndrome

By

Parswa Ansari

, MD, Hofstra Northwell-Lenox Hill Hospital, New York

Last full review/revision Dec 2019| Content last modified Dec 2019
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Topic Resources

Solitary rectal ulcer syndrome is a rare disorder that involves straining during defecation, a sense of incomplete evacuation, and sometimes passage of blood and mucus by rectum. It is caused by localized ischemic injury or prolapse of the distal rectal mucosa. Diagnosis is clinical with confirmation by flexible sigmoidoscopy and biopsy. Treatment is a bowel regimen for mild cases, but surgery is sometimes needed if rectal prolapse is the cause.

Solitary rectal ulcer syndrome is caused by mucosal ischemia of the distal rectal mucosa resulting from trauma.

Causes include

  • Paradoxical contraction of the puborectalis muscle

  • Chronic constipation

  • Attempts at manual disimpaction of hard stools

Symptoms and Signs

Affected patients have straining during defecation, a sense of incomplete evacuation or pelvic fullness, and sometimes passage of blood and mucus by rectum.

The syndrome is poorly named because associated lesions may be solitary or multiple and ulcerated or nonulcerated; they range from mucosal erythema to ulcers to small mass lesions. Lesions are typically located in the anterior rectal wall within 10 cm of the anal verge.

Pearls & Pitfalls

  • Solitary rectal ulcer syndrome is poorly named because associated lesions may be solitary or multiple and ulcerated or nonulcerated; they range from mucosal erythema to ulcers to small mass lesions.

Diagnosis

  • Clinical evaluation

  • Flexible sigmoidoscopy with biopsy

Diagnosis of solitary rectal ulcer syndrome is typically made by clinical history alone, but flexible sigmoidoscopy with biopsy is sometimes done for confirmation. Assessment for internal or full-thickness rectal prolapse should be done (see diagnosis of rectal prolapse).

Histopathologic examination of the biopsy specimen shows a thickened mucosal layer with distortion of the crypt architecture and replacement of the lamina propria with smooth muscle and collagen, leading to hypertrophy and disorganization of the muscularis mucosa.

Treatment

  • Bulk laxatives

  • Sometimes surgery for rectal prolapse

Mild cases are treated with reassurance and establishment of a bowel regimen with bulk laxatives to relieve chronic constipation.

If rectal prolapse is the cause, surgery may be needed (see treatment of rectal prolapse).

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