Solitary rectal ulcer syndrome
- David J Kim, MD
David J Kim, MD
- Northwest Gastroenterologists
- Peter A L Bonis, MD
Peter A L Bonis, MD
- Chief Medical Officer of Clinical Effectiveness (UpToDate, Clinical Drug Information, and Emmi Solutions)
- Deputy Editor — Gastroenterology/Hepatology
- Adjunct Professor of Medicine
- Tufts University School of Medicine
Solitary rectal ulcer syndrome is an uncommon rectal disorder that can present with rectal bleeding, straining during defecation, and a sense of incomplete evacuation [1,2]. The term solitary rectal ulcer syndrome is a misnomer. Endoscopic findings in patients with solitary rectal ulcer syndrome can range from mucosal erythema alone to single or multiple ulcers and polypoid/mass lesions. This topic will review the pathogenesis, clinical manifestations, diagnosis, and management of solitary rectal ulcer syndrome. Other causes of chronic colonic ulceration, including ulcerative colitis, Crohn disease, and ischemic colitis, are discussed in detail, separately. (See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults" and "Clinical manifestations, diagnosis and prognosis of Crohn disease in adults" and "Colonic ischemia".)
The incidence of solitary rectal ulcer syndrome is uncertain but has been estimated in one study to be 1 in 100,000 individuals per year . In one retrospective study of 80 patients, the median age at diagnosis was 48 years with a range of 14 to 76 years . Men and women appear to be affected equally, but a slight female preponderance has been suggested in various reports.
The pathogenesis of the solitary rectal ulcer is incompletely understood. However, a number of factors appear to have a causative role in individual reports. It is possible that different etiologies may contribute to the development of the final lesion.
A common observation in a number of reports is rectal prolapse and paradoxical contraction of the puborectalis muscle, which can result in rectal trauma by two different mechanisms [5,6]:
●Prolapsed rectal mucosa is forced downward due to the pressures generated by the rectum during defecation. The opposing force of the paradoxical contraction of the puborectalis muscle can generate high pressures within the rectum and lead to mucosal ischemia, thus predisposing to ulceration.
- Cruveilhier J. Ulcere chronique du rectum. In: Anatomie pathologique du corps humain, JB Bailliere, Paris 1829.
- Madigan MR, Morson BC. Solitary ulcer of the rectum. Gut 1969; 10:871.
- Martin CJ, Parks TG, Biggart JD. Solitary rectal ulcer syndrome in Northern Ireland. 1971-1980. Br J Surg 1981; 68:744.
- Tjandra JJ, Fazio VW, Church JM, et al. Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum 1992; 35:227.
- Morio O, Meurette G, Desfourneaux V, et al. Anorectal physiology in solitary ulcer syndrome: a case-matched series. Dis Colon Rectum 2005; 48:1917.
- Rao SS, Ozturk R, De Ocampo S, Stessman M. Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome. Am J Gastroenterol 2006; 101:613.
- Halligan S, Nicholls RJ, Bartram CI. Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse. AJR Am J Roentgenol 1995; 164:91.
- Sood SK, Garner JP, Amin SN. Spontaneous resolution of solitary rectal ulcer syndrome during pregnancy: report of a case. Dis Colon Rectum 2008; 51:1149.
- Tjandra JJ, Fazio VW, Petras RE, et al. Clinical and pathologic factors associated with delayed diagnosis in solitary rectal ulcer syndrome. Dis Colon Rectum 1993; 36:146.
- Bulut T, Canbay E, Yamaner S, et al. Solitary rectal ulcer syndrome: exploring possible management options. Int Surg 2011; 96:45.
- Ong J, Lim KH, Lim JF, Eu KW. Solitary caecal ulcer syndrome: our experience with this benign condition. Colorectal Dis 2011; 13:786.
- Blanco F, Frasson M, Flor-Lorente B, et al. Solitary rectal ulcer: ultrasonographic and magnetic resonance imaging patterns mimicking rectal cancer. Eur J Gastroenterol Hepatol 2011; 23:1262.
- Ignjatovic A, Saunders BP, Harbin L, Clark S. Solitary 'rectal' ulcer syndrome in the sigmoid colon. Colorectal Dis 2010; 12:1163.
- Levine DS. "Solitary" rectal ulcer syndrome. Are "solitary" rectal ulcer syndrome and "localized" colitis cystica profunda analogous syndromes caused by rectal prolapse? Gastroenterology 1987; 92:243.
- Goei R, Baeten C, Janevski B, van Engelshoven J. The solitary rectal ulcer syndrome: diagnosis with defecography. AJR Am J Roentgenol 1987; 149:933.
- Mahieu PHG. Barium enema and defecography in the diagnosis and evaluation of the solitary rectal ulcer syndrome. Int J Colorectal Dis 1986; 1:85.
- Halligan S, Sultan A, Rottenberg G, Bartram CI. Endosonography of the anal sphincters in solitary rectal ulcer syndrome. Int J Colorectal Dis 1995; 10:79.
- Marshall M, Halligan S, Fotheringham T, et al. Predictive value of internal anal sphincter thickness for diagnosis of rectal intussusception in patients with solitary rectal ulcer syndrome. Br J Surg 2002; 89:1281.
- Tsironi E, Irving PM, Feakins RM, Rampton DS. "Diversion" colitis caused by Clostridium difficile infection: report of a case. Dis Colon Rectum 2006; 49:1074.
- Daya D, O'Connell G, DeNardi F. Rectal endometriosis mimicking solitary rectal ulcer syndrome. Mod Pathol 1995; 8:599.
- Torres C, Khaikin M, Bracho J, et al. Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes. Int J Colorectal Dis 2007; 22:1389.
- Rao SS, Benninga MA, Bharucha AE, et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil 2015; 27:594.
- Malouf AJ, Vaizey CJ, Kamm MA. Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome. Dis Colon Rectum 2001; 44:72.
- Jarrett ME, Emmanuel AV, Vaizey CJ, Kamm MA. Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow. Gut 2004; 53:368.
- Halligan S, Nicholls RJ, Bartram CI. Proctographic changes after rectopexy for solitary rectal ulcer syndrome and preoperative predictive factors for a successful outcome. Br J Surg 1995; 82:314.
- Niv Y, Bat L. Solitary rectal ulcer syndrome--clinical, endoscopic, and histological spectrum. Am J Gastroenterol 1986; 81:486.
- Sitzler PJ, Kamm MA, Nicholls RJ, McKee RF. Long-term clinical outcome of surgery for solitary rectal ulcer syndrome. Br J Surg 1998; 85:1246.
- Tweedie DJ, Varma JS. Long-term outcome of laparoscopic mesh rectopexy for solitary rectal ulcer syndrome. Colorectal Dis 2005; 7:151.
- Stavorovsky M, Weintroub S, Ratan J, Rozen P. Successful treatment of a benign solitary rectal ulcer by temporary diverting sigmoidostomy: report of a case. Dis Colon Rectum 1977; 20:347.
- Zargar SA, Khuroo MS, Mahajan R. Sucralfate retention enemas in solitary rectal ulcer. Dis Colon Rectum 1991; 34:455.
- Kochhar R, Mehta SK, Aggarwal R, et al. Sucralfate enema in ulcerative rectosigmoid lesions. Dis Colon Rectum 1990; 33:49.
- Höpfner M, Nitsche R, Rohr A, et al. Yersinia enterocolitica infection with multiple liver abscesses uncovering a primary hemochromatosis. Scand J Gastroenterol 2001; 36:220.
- Vaizey CJ, Roy AJ, Kamm MA. Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback. Gut 1997; 41:817.
- Dehghani SM, Haghighat M, Imanieh MH, Geramizadeh B. Solitary rectal ulcer syndrome in children: a prospective study of cases from southern Iran. Eur J Gastroenterol Hepatol 2008; 20:93.
- Somani SK, Ghosh A, Avasthi G, et al. Healing of a bleeding solitary rectal ulcer with multiple sessions of argon plasma. Gastrointest Endosc 2010; 71:578.
- Meurette G, Siproudhis L, Regenet N, et al. Poor symptomatic relief and quality of life in patients treated for "solitary rectal ulcer syndrome without external rectal prolapse". Int J Colorectal Dis 2008; 23:521.
- CLINICAL FEATURES
- Clinical manifestations
- Imaging findings
- Endoscopy and histology
- ADDITIONAL EVALUATION
- Endoscopic ultrasound
- DIFFERENTIAL DIAGNOSIS
- Management approach
- Conservative treatment
- SUMMARY AND RECOMMENDATIONS