The solitary rectal ulcer syndrome

The solitary rectal ulcer syndrome is a rare debilitating disorder of the rectum characterized by perianal chronic pain with passage of blood and mucus. The pathogenesis remains uncertain, rectal prolapse and trauma from straining are the main hypothesis. The diagnosis includes clinical symptoms associated with endoscopic lesion (erythema, ulcer or polypo?d lesion) and histological features. Mano-metric studies and defecography are helpful to determinate an underlying defecation disorder or rectal prolapse. The treatment is controversial including a conservative option (medications and behavioural therapy) with poor long term results, and the surgical option (treatment of a rectal prolapse with or without resection of the lesion), more aggressive with uncertain results in a long follow-up period.     

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.     

Pathology of the rectal wall in solitary rectal ulcer syndrome and complete rectal prolapse.

BACKGROUND--The aetiology and pathology of rectal prolapse and solitary rectal ulcer are poorly understood. AIMS--To examine the full thickness rectal wall in these two conditions. METHODS--The pathological abnormalities in the surgically resected rectal wall were studied from nine patients with solitary rectal ulcer syndrome, 11 complete rectal prolapse, and nine cancer controls. Routine haematoxylin and eosin and Van Gieson staining for collagen were performed. RESULTS--The rectal wall from solitary rectal ulcer syndrome specimens was thickened compared with complete rectal prolapse and controls. The major difference was in the muscularis propria (2.2 v 1.1 v 1.2 mm, medians, p < 0.005) and particularly the inner circular muscular layer, and to a lesser extent the submucosal and outer longitudinal muscular layers. Some solitary rectal ulcer syndrome specimens showed unique features such as decussation of the two muscular layers (four of nine), nodular induration of inner circular layer (four of nine) and grouping of outer longitudinal layer into bundles (three of nine); these were not seen in complete rectal prolapse or control specimens. CONCLUSIONS--These features, which resemble the features of high pressure sphincter tissue, may be of aetiological importance, and suggest a different pathogenesis for these two disorders. Excess collagen was seen in both disorders, was more severe in solitary rectal ulcer syndrome specimens, and probably reflects a response to repeated trauma.     

Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.     

Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome.

Transrectal ultrasonography is of clinical value in anorectal carcinoma and in inflammatory diseases of the anorectum. In this study a rigid linear endorectal probe was used to examine 15 patients with endoscopically and biopsy proved diagnosis of solitary rectal ulcer syndrome. In 13 of the 15 patients the rectal wall was thicker (mean (SEM) 5.7 (0.4) mm; normal values: 2.8 (0.1) mm) near the rectal ulcer. In all these cases the muscularis propria layer exceeded the maximum normal diameter of 2 mm. In nine of the 15 patients the normal rectal wall echo-structure, with five distinct layers, was disturbed and there was fading of the borders between the mucosa and the muscularis propria. Poor relaxation of the puborectalis muscle during straining was seen on ultrasound in 11 patients, as was intussusception of the rectal wall. The obvious enlargement of the muscularis propria points to a chronic mechanical load on the rectal wall. The ulcerative lesions are formed in this area of overloaded rectal wall. The direct visualisation of the puborectalis muscle during dynamic transrectal ultrasonography indicates that the fact that it does not relax is an important element in the pathogenesis of solitary rectal ulcer syndrome.     

Nonsurgical therapy for solitary rectal ulcer syndrome

Opinion statement  

"Solitary" rectal ulcer syndrome. Are "solitary" rectal ulcer syndrome and "localized" colitis cystica profunda analogous syndromes caused by rectal prolapse?

The hypothesis that SRUS and localized CCP are analogous syndromes is supported by the similarities in clinical presentation and biopsy pathology of patients with these conditions. The theory that rectal mucosal prolapse causes SRUS and localized CCP is strengthened by the observation of like pathology in other clinical situations and various animal models in which mucosal prolapse occurs. However, rectal prolapse is not clinically demonstrable in all patients. Therefore, the definitive diagnosis of SRUS and localized CCP must depend upon the recognition of specific histopathologic features in rectal biopsy specimens from ulcer margins or otherwise abnormal mucosa. Conservative medical management is satisfactory for most patients, and surgical intervention should be reserved for highly selected patients.     

Anorectal function in the solitary rectal ulcer syndrome

The anorectal function of nine patients with solitary rectal ulcer syndrome (SRUS) (5 F: 4 M, median age, 27 (range, 19–41 years) and nine control subjects (5 F: 4 M, median age, 47 (35–66)P<0.01) has been investigated by a new technique that radiologically visualizes the anorectum during voiding of a semisolid contrast medium, while simultaneously measuring intrarectal pressure and anal sphincter EMG activity. A degree of rectal prolapse was demonstrated in eight of the SRUS patients; six of these lesions were clinically occult. Abnormal failure of the anal sphincter to relax on voiding was present in seven of the SRUS patients. These abnormalities resulted in the SRUS patients requiring a greater increase in intrarectal pressure (median, 100 cm water) to void than the control subjects (median, 65 cm water,P<0.01). This combination of high intrarectal pressure and rectal prolapse during straining seems to be the cause of SRUS This work was supported by a grant from the Medical Research Council.     

The investigation of anorectal dysfunction in the solitary rectal ulcer syndrome

To investigate anorectal function in solitary rectal ulcer syndrome 22 patients were studied by means of balloon expulsion, intestinal transit time, barium enema and evacuation proctography. Half of the patients tested had difficulty in expelling a water filled balloon. Delay in intestinal transit was noted in only three patients. Barium enema was of little benefit in diagnosing the condition. Evacuation proctography was the investigation of choise in that it showed at least one abnormality of pelvic floor function in all of the patients and can help select patients for surgery.     

Argon plasma coagulation of hemorrhagic solitary rectal ulcer syndrome

Solitary ulcer syndrome (SUS) is a rare disorder that may provoke hematochezia. Argon plasma coagulation (APC) is used in a wide range of gastrointestinal bleeding. We experienced APC in a patient with a bleeding gigantic SUS: a 64-year-old woman who developed a SUS at 60. After 3 years, recurrent hematochezia, secondary anemia, and rectal pain occurred. Endoscopy revealed a large rectal bleeding ulcer. Moreover, the pain led the patient to assume analgesics. These conditions stimulated us to treat this ulcer with APC within 4 sessions; each session spaced out at 30-day intervals. The patient experienced and maintained the following benefits: (1) resolution of bleeding and secondary anemia after the first session, (2) reduction of ulcer depth, disappearance of pain and analgesic withdrawal at the end of the cycle, (3) almost complete endoscopic healing of the ulcer after 9 months of follow-up. This experience suggests that APC may represent a therapeutic approach for bleeding SUS even if controlled studies are necessary before recommending it as acceptable treatment.     

An unusual endoscopic presentation of solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome (SRUS) is an uncommon rectal disorder. Massive rectal bleeding is a rare presentation of SRUS, and can pose an endoscopic challenge in differentiating from other causes of massive rectal bleeding. A 22-year-old man presented with massive rectal bleeding which had SRUS with spurting bleeding on lower endoscopic evaluation. He was treated by endoscopic hemostasis using argon plasma coagulation. He had no complaint after a month and follow up lower endoscopy proved complete healing within two months. SRUS should be considered as a potential cause of massive rectal bleeding.     

Clinical and manometric features of the solitary rectal ulcer syndrome

We report 33 patients with the solitary rectal ulcer syndrome seen between 1975 and 1982. Twenty-four were women and the median age was 32 years. The principal symptoms were bleeding (89 per cent), chronic constipation (64 per cent), rectal pain (42 per cent), tenesmus (42 per cent), and mucous discharge (45 per cent). Twenty-eight patients gave a history of straining (85 per cent). A full-thickness rectal prolapse was present in six patients, an anterior rectal prolapse was observed in 11, and 12 patients had clinical evidence of perineal descent. Defecation was only possible by digital evacuation in six women, and three male patients were passive homosexuals. Manometric studies were performed on 16 patients; eight patients were unable to tolerate rectal distension with 200 cc of air and impaired rectal sensation was present in two. Rectal distention was associated with bursts of involuntary external sphincter activity in three patients, and the distention reflex was absent in six, despite normal ganglia on rectal biopsy. In only four patients was there electromyographic evidence of contraction of the puborectalis during attempted defecation. Fourteen patients were treated by rectopexy; healing of the ulcer occurred in five of six with a full-thickness prolapse compared with only two of eight without a complete prolapse. Work performed at the General Hospital, Birmingham, England.     

Radiaton-induced solitary rectal ulcer

A case of radiation-induced solitary rectal ulcer is presented. The unusual posterior location with involvement of the internal iliac artery produced massive lower intestinal hemorrhage. Temporary control was obtained with percutaneous arterial catheter embolization, but definitive control necessitated surgical resection.