Jump to content

Solitary rectal ulcer syndrome: Difference between revisions

From Wikipedia, the free encyclopedia
Browse history interactively
← Previous edit
Content deleted Content added
VisualWikitext
m Typo fixing and cleanup, typos fixed: conditon → condition using AWB
OAbot (talk | contribs)
Bots
441,761 edits
m Open access bot: doi updated in citation with #oabot.
 
(39 intermediate revisions by 12 users not shown)
Line 1: Line 1:
{{Short description|Medical condition}}
'''Solitary rectal ulcer syndrome''' (SRUS, SRU), is a disorder of the [[rectum]] and [[anal canal]], caused by straining and increased pressure during [[defecation]]. This increased pressure causes the anterior portion of the rectal lining to be forced into the anal canal (an [[Internal intussusception]]). The lining of the rectum is repeatedly damaged by this friction, resulting in [[ulceration]]. SRUS can therefore considered to be a consequence of [[internal intussusception]] (a sub type of [[rectal prolapse]]), which can be demonstrated in 94% of cases. It may be [[asymptomatic]], but it can cause [[rectal pain]], [[rectal bleeding]], [[rectal malodor]], incomplete evacuation and obstructed defecation ([[outlet obstruction]]).
{{Infobox medical condition (new)
| name = Solitary rectal ulcer syndrome
| synonyms = Solitary rectal ulcer
| image =
| caption =
| field = [[Colorectal surgery]]
| pronounce =
| symptoms =
| complications =
| onset =
| duration =
| types =
| causes =
| risks =
| diagnosis =
| differential =
| prevention =
| treatment =
| medication =
| prognosis =
| frequency =
| deaths =
}}


'''Solitary rectal ulcer syndrome''' ('''SRUS''' or '''SRU''') is a chronic disorder of the rectal [[Mucous membrane|mucosa]] (the lining of the rectum).<ref name="Alejandra2019" /> Very often but not always it occurs in association with varying degrees of [[rectal prolapse]]. The condition is thought to be caused by different factors, such as long term [[constipation]], straining during defecation, and [[dyssynergic defecation]] (anismus). Treatment is by normalization of bowel habits, [[biofeedback]], and other conservative measures. In more severe cases, various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with [[rectal cancer]] or other conditions such as [[inflammatory bowel disease]], even when a [[biopsy]] is done.<ref name="Herold2017" />
==Symptoms==
Symptoms include:<ref name=yamada>{{cite book|last=al.]|first=edited by Tadataka Yamada ; associate editors, David H. Alpers ... [et|title=Textbook of gastroenterology|year=2009|publisher=Blackwell Pub.|location=Chichester, West Sussex|isbn=978-1-4051-6911-0|pages=1728|edition=5th ed.}}</ref><ref name=abid>{{cite journal|last=Abid|first=S|coauthors=Khawaja, A; Bhimani, SA; Ahmad, Z; Hamid, S; Jafri, W|title=The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases.|journal=BMC gastroenterology|date=2012-06-14|volume=12|issue=1|pages=72|pmid=22697798}}</ref><ref name="mackle" />
* Straining during [[defecation]]
* Mucous [[rectal discharge]]
* [[Rectal bleeding]]
* Sensation of incomplete evacuation ([[tenesmus]])
* [[constipation]], or more rarely [[diarrhea]]
* [[fecal incontinence]] (rarely)


==Signs and symptoms==
==Prevalence==
The signs and symptoms are variable, and in up to 25% of patients there may be no symptoms.<ref name="Forootan2018" /> The most common signs and symptoms are bleeding, which can vary from minor to severe, rectal prolapse and incomplete evacuation (35%-76% of cases).<ref name="Qari2020" /> According to one report, constipation is present in about 55% of cases, but diarrhea is present in 20%–40% of cases.<ref name="Alejandra2019" /> Reported symptoms are:
The condition is thought to be uncommon. It usually occurs in young adults, but children can be affected too.<ref name=ertem>{{cite journal|last=Ertem|first=D|coauthors=Acar, Y; Karaa, EK; Pehlivanoglu, E|title=A rare and often unrecognized cause of hematochezia and tenesmus in childhood: solitary rectal ulcer syndrome.|journal=Pediatrics|date=2002 Dec|volume=110|issue=6|pages=e79|pmid=12456946}}</ref>


* [[Hematochezia]] (lower gastrointestinal bleeding).<ref name="Sadeghi2019" /> which can vary from minor to severe.<ref name="Forootan2018" />
==Cause==
* Rectal pain.<ref name="Forootan2018" />
The essential cause of SRUS is thought to be related to too much straining during defecation.
* Pelvic discomfort.<ref name="Forootan2018" />
* Tenesmus.<ref name="Forootan2018" />
* Sensation of incomplete evacuation of stool.<ref name="Forootan2018" />
* Mucous rectal discharge ([[Mucorrhea]]).<ref name="Forootan2018" />
* Constipation, which may be chronic and severe.<ref name="Forootan2018" />
* Straining during defecation.<ref name="Forootan2018" />
* [[Rectal prolapse]] or other [[pelvic floor disorder]]s.
* Repeated use of laxatives.<ref name="Forootan2018" />
* [[Fecal incontinence]].<ref name="Gouriou2018" />
* Diarrhea.<ref name="Alejandra2019" />


==Causes==
Overactivity of the anal sphincter during defecation causes the patient to require more effort to expele stool. This pressure is produced by the modified valsalva manovoure (attempted forced exhalation against a closed glottis, resulting in increased abdominal and intra-rectal pressure). Patiest with SRUS were shown to have higher intra-rectal pressures when straining than healthy controls.<ref>{{cite journal|last=Womack|first=NR|coauthors=Williams, NS; Holmfield, JH; Morrison, JF|title=Pressure and prolapse--the cause of solitary rectal ulceration.|journal=Gut|date=1987 Oct|volume=28|issue=10|pages=1228–33|pmid=3678951}}</ref> SRUS is also associated with prolonged and incomplete evacuation of stool.<ref name=halligan>{{cite journal|last=Halligan|first=S|coauthors=Nicholls, RJ; Bartram, CI|title=Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse.|journal=AJR. American journal of roentgenology|date=1995 Jan|volume=164|issue=1|pages=91–5|pmid=7998576}}</ref>
The exact cause is unclear and the condition is not fully understood.<ref name="Forootan2018" /> There are thought to be multiple factors which simultaneously cause the condition.<ref name="Forootan2018" /> Long term injury to the rectal mucosa and ischemic trauma are thought to be the main mechanisms.<ref name="Sadeghi2019" /> In a report of 36 patients with SRUS, the underlying cause was internal prolapse (intussusception) in 20 patients, external rectal prolapse in 14 patients, and dyssynergic defecation (anismus) in 2 patients.<ref name="George2016" />


===Direct trauma===
More effort is required because of concomitant [[anismus]], or non-relaxation/paradoxical contraction of [[puborectalis]] (which should normally relax during defecation).<ref name=van>{{cite journal|last=Van Outryve|first=MJ|coauthors=Pelckmans, PA; Fierens, H; Van Maercke, YM|title=Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome.|journal=Gut|date=1993 Oct|volume=34|issue=10|pages=1422–6|pmid=8244113}}</ref> The increased pressure forces the anterior rectal lining against the contracted puborectalis and frequently the lining prolapses into the anal canal during straining and then returns to its normal position afterwards.
Self-digitation is when individuals with constipation resort to inserting a finger into the rectum in order to "hook out" fecal pellets or to apply pressure to an obstructing lesion (see: [[obstructed defecation]]). The rectal mucosa is fragile and vulnerable to trauma when such manoeuvres are performed chronically. It is thought that this self-induced trauma is one possible mechanism of SRUS.<ref name="Alejandra2019" /> However, since sometimes the location of SRUS lesion(s) is much further than a finger could reach means that this cannot be the only cause.<ref name="Sadeghi2019" /> In constipation, the stools may be very hard and this is another possible mechanism of trauma.<ref name="Alejandra2019" />


===Excessive straining: chronic constipation, dyssynergic defecation===
The repeated trapping of the lining can cause the tissue to become swollen and congested. Ulceration is thought to be caused by resulting poor blood supply ([[ischemia]]), combined with repeated frictional trauma from the prolapsing lining, and exposure to increased pressure are thought to cause ulceration. Trauma from hard stools may also contribute.
People with constipation or certain anatomical anomalies are more likely to end up using excessive straining during defecation attempts.<ref name="Sadeghi2019" /> Prolonged straining may cause direct trauma to the rectal mucosa.<ref name="Sadeghi2019" /> Most patients with SRUS have [[dyssynergic defecation]] (previously termed anismus).<ref name="Kuckelman2019" /> This is a failure of relaxation (or paradoxical contraction) of the [[puborectalis muscle]] during defecation attempts. This pelvic floor muscle is normally supposed to relax, thereby straightening the anorectal angle and allowing rectal contents to be evacuated. Dyssynergic defecation causes high pressure in the rectum and in the anal canal,<ref name="Alejandra2019" /> which causes lengthening<ref name="Alejandra2019" /> and compression of the rectal tissues, which in turn leads to ischema of the mucosa.<ref name="Kuckelman2019" /> There is also a shearing movement of the rectum against the pelvic floor muscles.<ref name="Kuckelman2019" /> In the long term this leads to repeated mucosal damage.<ref name="Kuckelman2019" /> Inappropriate contraction of puborectalis in the squatting position causes traumatic compression of the rectal wall against the anal canal.<ref name="Sadeghi2019" /> Also, it is reported that individuals with SRUS have not only increased pressure when squeezing, but also higher resting pressure compared to normal controls.<ref name="Sadeghi2019" />


===Rectal prolapse and ischemic injury===
The site of the ulcer is typically on the [[anterior]] wall of the [[rectal ampulla]], about 7–10&nbsp;cm from the anus. However, the area may of ulceration may be closer to the anus, deeper inside, or on the lateral or posterior rectal walls. The name "solitary" can be misleading since there may be more than one ulcer present. Furthermore, there is a "preulcerative phase" where there is no ulcer at all.<ref>{{cite journal|last=Madigan|first=MR|coauthors=Morson, BC|title=Solitary ulcer of the rectum.|journal=Gut|date=1969 Nov|volume=10|issue=11|pages=871–81|pmid=5358578}}</ref>
SRUS is usually accompanied by prolapse (e.g. external prolapse or rectoanal intussusception/internal prolapse) or other pelvic-floor disorders.<ref name="Alejandra2019" /><ref name="George2016">{{cite book | vauthors = George B, Guy R, Jones O, Vogel J |title=Colorectal Surgery: Clinical Care and Management |date=2 May 2016 |publisher=John Wiley & Sons |location=Chichester, West Sussex, UK |isbn=978-1-118-67478-9 |language=en}}</ref> This is association is common, but not always present.<ref name="Rao2020" /> Some state that if SRUS is not treated, it would always tend to progress to rectal prolapse.<ref name="Sadeghi2019" /> The relationship of SRUS with [[rectal prolapse]] and rectal cystitis profunda is debated.<ref name="Kuckelman2019" /> Some see SRUS and prolapse as synonymous, while others see them as separate entities,<ref name="Kuckelman2019" /> and state that they do not share the same physiology.<ref name="Gouriou2018" /> For example, the mucosal changes that occur with external rectal prolapse can be separated from the mucosal changes seen in SRUS.<ref name="Gouriou2018" />


The excessive pressure caused by straining (i.e. dyssynergic defecation and constipation) may in the long term lead to development of the spectrum of rectal prolapse conditions (mucosal versus full-thickness prolapse, internal versus external rectal prolapse).<ref name="Sadeghi2019" /> These conditions create chronic vascular trauma (ischemia or hypoperfusion) in the rectal mucosa,<ref name="Alejandra2019" /> which predisposes it to ulceration,<ref name="Kuckelman2019" /> and pressure necrosis.<ref name="Qari2020" /> Even the initial small areas of an intussusception can lead to vascular injury and reduce blood supply to the region.<ref name="Sadeghi2019" /> This is the first stage of ulcer development.<ref name="Sadeghi2019" />
Pathological specimens of sections of rectal wall taken from SRUS patients show thickening and replacement of muscle with fibrous tissue and excess collagen.<ref>{{cite journal|last=Kang|first=YS|coauthors=Kamm, MA; Engel, AF; Talbot, IC|title=Pathology of the rectal wall in solitary rectal ulcer syndrome and complete rectal prolapse.|journal=Gut|date=1996 Apr|volume=38|issue=4|pages=587–90|pmid=8707093}}</ref> rarely, SRUS can present as polyps in the rectum.<ref>{{cite journal|last=Brosens|first=LA|coauthors=Montgomery, EA; Bhagavan, BS; Offerhaus, GJ; Giardiello, FM|title=Mucosal prolapse syndrome presenting as rectal polyposis.|journal=Journal of clinical pathology|date=2009 Nov|volume=62|issue=11|pages=1034–6|pmid=19861563}}</ref><ref>{{cite journal|last=Saadah|first=OI|coauthors=Al-Hubayshi, MS; Ghanem, AT|title=Solitary rectal ulcer syndrome presenting as polypoid mass lesions in a young girl.|journal=World journal of gastrointestinal oncology|date=2010-08-15|volume=2|issue=8|pages=332–4|pmid=21160895}}</ref>


===Other factors===
SRUS is therefore associated and with internal, and more rarely, external rectal prolapse.<ref name="halligan" /> Some believe that SRUS represents a spectrum of different diseases with different [[etiologies]].<ref>{{cite journal|last=Kang|first=YS|coauthors=Kamm, MA; Nicholls, RJ|title=Solitary rectal ulcer and complete rectal prolapse: one condition or two?|journal=International journal of colorectal disease|year=1995|volume=10|issue=2|pages=87–90|pmid=7636379}}</ref>
Psychological factors are also thought to be involved, since patients with SRUS sometimes have psychological disorders such as [[obsessive-compulsive disorder]].<ref name="Alejandra2019" /> Also, some unknown factors may also be involved, such as hormonal factors related to pregnancy.<ref name="Sadeghi2019" /> Other possible factors are rectal hypersensitivity,<ref name="Qari2020" /> and impaired rectal evacuation of stool.<ref name="Rao2020" />


==Diagnosis==
Another condition associated with internal intussusception is [[colitis cystica profunda]] (CCF, proctitis cystica profunda), which is [[cystica profunda]] in the rectum. Cystica profunda is characterised by formation of [[mucin]] [[cysts]] in the muscle layers of the gut lining, and it can occur anywhere along the gastrointestinal tract. When it occurs in the rectum, some believe to be an interchangeable diagnosis with SRUS since the [[histological]] features of the conditions overlap.<ref>{{cite journal|last=Vora|first=IM|coauthors=Sharma, J; Joshi, AS|title=Solitary rectal ulcer syndrome and colitis cystica profunda--a clinico-pathological review.|journal=Indian journal of pathology & microbiology|date=1992 Apr|volume=35|issue=2|pages=94–102|pmid=1483723}}</ref><ref name="levine">{{cite journal|last=Levine|first=DS|title="Solitary" rectal ulcer syndrome. Are "solitary" rectal ulcer syndrome and "localized" colitis cystica profunda analogous syndromes caused by rectal prolapse?|journal=Gastroenterology|date=1987 Jan|volume=92|issue=1|pages=243–53|pmid=3536653}}</ref> Indeen, CCF is managead identically to SRUS.<ref>{{cite journal|last=Beck|first=DE|title=Surgical Therapy for Colitis Cystica Profunda and Solitary Rectal Ulcer Syndrome.|journal=Current treatment options in gastroenterology|date=2002 Jun|volume=5|issue=3|pages=231–237|pmid=12003718}}</ref>
Diagnosis is difficult because of rarity of the condition and because of the variability of the symptoms and the histologic appearance.<ref name="Alejandra2019" /><ref name="Sadeghi2019" /> The condition is sometimes misdiagnosed.<ref name="Alejandra2019" /> Clinicians may not be familiar with the condition, and treat for [[inflammatory bowel disease]], or simple constipation.<ref name=black>{{cite journal | vauthors = Blackburn C, McDermott M, Bourke B | title = Clinical presentation of and outcome for solitary rectal ulcer syndrome in children | journal = Journal of Pediatric Gastroenterology and Nutrition | volume = 54 | issue = 2 | pages = 263–265 | date = February 2012 | pmid = 22266488 | doi = 10.1097/MPG.0b013e31823014c0 | s2cid = 27955947 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Umar SB, Efron JE, Heigh RI | title = An interesting case of mistaken identity | journal = Case Reports in Gastroenterology | volume = 2 | issue = 3 | pages = 308–313 | date = September 2008 | pmid = 21490861 | pmc = 3075189 | doi = 10.1159/000154816 }}</ref> Diagnosis may be delayed by many years as a result.<ref name="Qari2020" />


===Differential diagnosis===
A group of conditions known as "Mucosal prolapse syndrome" (MPS) has now been recognized. It includes SRUS, rectal prolapse, proctitis cystica profunda, and inflammatory polyps.<ref name="abid" /><ref name="nonaka" /> It is classified as a chronic benign inflammatory disorder. The unifying feature is varying degrees of rectal prolapse, whether internal intussusception (occult prolapse) or external prolapse.
The [[differential diagnosis]] is as follows:
* [[Inflammatory bowel disease]] (IBD).<ref name="Alejandra2019" />
* [[Colorectal cancer|rectal neoplasms]] (bowel cancer).<ref name="Alejandra2019" /><ref name="Gouriou2018" />
* Chronic vascular insufficiency ([[ischaemic colitis]]).<ref name="Gouriou2018" />
* Infectious diseases (e.g. [[amebiasis]], [[lymphogranuloma venereum]], [[syphilis]]).<ref name="Alejandra2019" />
* [[Rectal endometriosis]].<ref name="Sadeghi2019" />
* Drugs.<ref name="Sadeghi2019" />
* [[Colitis cystica profunda]].<ref name="Alejandra2019" />
* Drug induced ulcer.<ref name="Alejandra2019" />
* Pressure ulcer.<ref name="Alejandra2019" />
* Trauma.<ref name="Alejandra2019" />
* Idiopathic (i.e. unknown cause).<ref name="Alejandra2019" />


===Investigations===
Electromyography may show [[pudendal nerve]] motor latency.<ref name="abid" />
Investigations used in the diagnosis of SRUS include [[defecography]], [[endoanal ultrasound]], [[colonoscopy]] and histological examination of a [[biopsy]].<ref name="Forootan2018" />


==Complications==
====Colonoscopy====
The macroscopic appearance of SRUS is very variable.<ref name="Kuckelman2019" /> Indeed, the condition has been referred to as “the three-lies disease”,<ref name="Qari2020" /> because the name of the condition is sometimes misleading. In reality, there may be more than one lesion, which may not be [[ulcer]]ative,<ref name="Kumagai2021">{{cite journal |last1=Kumagai |first1=H |last2=Yokoyama |first2=K |last3=Sunada |first3=K |last4=Yamagata |first4=T |title=Solitary rectal ulcer syndrome: A Misleading term. |journal=Pediatrics International |date=June 2021 |volume=63 |issue=6 |pages=739–740 |doi=10.1111/ped.14587 |pmid=34142735|s2cid=235463337 }}</ref> and the condition may appear in different parts of the gastrointestinal tract (i.e. other than the [[rectum]]).<ref name="Forootan2018" />


Classically, there is a solitary ulcer. But only 20% of patients have a single ulcer whereas in other cases there may be multiple lesions.<ref name="Gouriou2018" /> The size of the ulcers is usually 0.5–4&nbsp;cm.<ref name="Sadeghi2019" /> The lesion is most often located on the anterior (front) or lateral (side) rectal wall, centered on a rectal fold,<ref name="Alejandra2019" /> usually 10&nbsp;cm from the anal verge.<ref name="Kuckelman2019" /> Less commonly there may be ulcers in the [[anal canal]] or even in the [[sigmoid colon]].<ref name="Sadeghi2019" /> The nature of the tissue changes can vary from simple [[erythema]] (redness) / [[hyperaemia]] (increased blood flow) of the mucosa in 18% of cases,<ref name="Alejandra2019" /> to a chronic-appearing, small, shallow ulcer with nodular margins and a white or sloughing base.<ref name="Kuckelman2019" /><ref name="Alejandra2019" /> In up to 33% of cases there is no ulceration but instead one or more well-developed polyps or mass lesions.<ref name="Kuckelman2019" /><ref name="Sadeghi2019" /> There is usually mild [[proctitis]] (inflammation of the rectal mucosa) surrounding the ulcer.<ref name="Herold2017">{{cite book | vauthors = Herold A, Lehur PA, Matzel KE, O'Connell PR |title=European Manual of Medicine: Coloproctology |date=2017 |location=Berlin, Germany |isbn=978-3-662-53210-2 |edition=Second |language=en}}</ref>
Complications are uncommon, but include massive rectal bleeding, ulceration into the prostate gland or formation of a [[stricture]].<ref>{{cite journal|last=Gilrane|first=TB|coauthors=Orchard, JL; Al-Assaad, ZA|title=A benign rectal ulcer penetrating into the prostate--diagnosis by prostate-specific antigen.|journal=Gastrointestinal endoscopy|date=1987 Dec|volume=33|issue=6|pages=467–8|pmid=2450805}}</ref><ref>{{cite journal|last=Tseng|first=CA|coauthors=Chen, LT; Tsai, KB; Su, YC; Wu, DC; Jan, CM; Wang, WM; Pan, YS|title=Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature.|journal=Diseases of the colon and rectum|date=2004 Jun|volume=47|issue=6|pages=895-903; discussion 903-5|pmid=15129312}}</ref><ref>{{cite journal|last=Yagnik|first=VD|title=Massive rectal bleeding: rare presentation of circumferential solitary rectal ulcer syndrome.|journal=Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association|date=2011 Jul-Aug|volume=17|issue=4|pages=298|pmid=21727744}}</ref> Very rarely, cancer can arise on the section of prolapsed rectal lining.<ref name=nonaka>{{cite journal|last=Nonaka|first=T|coauthors=Inamori, M; Kessoku, T; Ogawa, Y; Yanagisawa, S; Shiba, T; Sakaguchi, T; Gotoh, E; Maeda, S; Nakajima, A; Atsukawa, K; Takahasi, H; Akasaka, Y|title=A case of rectal cancer arising from long-standing prolapsed mucosa of the rectum.|journal=Internal medicine (Tokyo, Japan)|year=2011|volume=50|issue=21|pages=2569–73|pmid=22041358}}</ref>


====Defecography====
==Diagnosis & Investigations==
Conventional defecography or magnetic resonance defecography may be used.<ref name="Alejandra2019" /> Between 50-100% of patients with SRUS will have abnormal defecography results.<ref name="Sadeghi2019" /> Defecography findings in SRUS may include:
* Evidence of dyssynergic defecation (anismus),<ref name="Kuckelman2019" /> 82% of patients with SRUS had dssynergic defecation in one report.<ref name="Alejandra2019" />
* Rectal intussusception (the most common finding in one report).<ref name="Sadeghi2019" />
* Anterior (front) or posterior (back) [[rectocele]].<ref name="Sadeghi2019" />
* Prolonged retention of [[contrast media]].<ref name="Sadeghi2019" />
* [[Megarectum]].<ref name="Sadeghi2019" />


====Endoanal ultrasound====
SRUS is commonly misdiagnosed, and the diagnosis is not made for 5–7 years.<ref name="ertem" /> Clinicians may not be familiar with the condition, and treat for Inflammatory bowel disease, or simple constipation.<ref name=black>{{cite journal|last=Blackburn|first=C|coauthors=McDermott, M; Bourke, B|title=Clinical presentation of and outcome for solitary rectal ulcer syndrome in children.|journal=Journal of pediatric gastroenterology and nutrition|date=2012 Feb|volume=54|issue=2|pages=263–5|pmid=22266488}}</ref><ref>{{cite journal|last=Umar|first=SB|coauthors=Efron, JE; Heigh, RI|title=An interesting case of mistaken identity.|journal=Case reports in gastroenterology|date=2008-09-30|volume=2|issue=3|pages=308–13|pmid=21490861}}</ref>
[[Endoanal ultrasound]] can determine the depth of the ulcer and the structure of the external and internal anal sphincters.<ref name="Kuckelman2019" /> Endoanal ultrasound findings in SRUS include:
* Lack of distinction between the mucosa and the [[muscularis propria]].<ref name="Alejandra2019" />
* Thickening of the rectal wall.<ref name="Sadeghi2019" />
* Thickening of [[muscularis propria]].<ref name="Alejandra2019" />
* Thickening of [[submucosa]]l layer.<ref name="Alejandra2019" />
* Thickening of [[internal anal sphincter]].<ref name="Alejandra2019" />
* Thickening of [[external anal sphincter]].<ref name="Alejandra2019" />
* Intussusception.<ref name="Sadeghi2019" />
* Multiple submucosal cysts.<ref name="Sadeghi2019" />
* Hyperechogenic bands of fibrosis in the submucosa layer.<ref name="Sadeghi2019" />
* Regional lymph node infiltration.<ref name="Sadeghi2019" />


====Anorectal manometry====
The thickened lining or ulceration can also be mistaken for types of cancer.<ref>{{cite journal|last=Amaechi|first=I|coauthors=Papagrigoriadis, S; Hizbullah, S; Ryan, SM|title=Solitary rectal ulcer syndrome mimicking rectal neoplasm on MRI.|journal=The British journal of radiology|date=2010 Nov|volume=83|issue=995|pages=e221-4|pmid=20965892}}</ref><ref>{{cite journal|last=Lokuhetty|first=D|coauthors=de Silva, MV; Mudduwa, L|title=Solitary rectal ulcer syndrome (SRUS) masquerading as a carcinomatous stricture.|journal=The Ceylon medical journal|date=1998 Dec|volume=43|issue=4|pages=241–2|pmid=10355182}}</ref><ref>{{cite journal|last=Blanco|first=F|coauthors=Frasson, M; Flor-Lorente, B; Minguez, M; Esclapez, P; García-Granero, E|title=Solitary rectal ulcer: ultrasonographic and magnetic resonance imaging patterns mimicking rectal cancer.|journal=European journal of gastroenterology & hepatology|date=2011 Nov|volume=23|issue=12|pages=1262–6|pmid=21971372}}</ref><ref>{{cite journal|last=Levine|first=DS|coauthors=Surawicz, CM; Ajer, TN; Dean, PJ; Rubin, CE|title=Diffuse excess mucosal collagen in rectal biopsies facilitates differential diagnosis of solitary rectal ulcer syndrome from other inflammatory bowel diseases.|journal=Digestive diseases and sciences|date=1988 Nov|volume=33|issue=11|pages=1345–52|pmid=2460300}}</ref>
As a diagnostic investigation, anorectal manometry can evaluate defecation function. It can highlight excessive and prolonged straining effort during defecation attempts, and also record any improvement in function before and after treatment interventions.<ref name="Maluenda2024">{{cite journal |last1=Maluenda A |first1=V |last2=Baeza I |first2=P |last3=Martínez M |first3=M |last4=Iriarte C |first4=MJ |last5=Bonomo M |first5=C |last6=Rojas A |first6=J |last7=Narváez J |first7=C |title=[What we know today about solitary rectal ulcer syndrome]. |journal=Revista medica de Chile |date=February 2024 |volume=152 |issue=2 |pages=225-234 |doi=10.4067/s0034-98872024000200225 |pmid=39450799|doi-access=free }}</ref> It is uncommonly used to diagnose SRUS, although biofeedback is still commonly used as a treatment.


====Biopsy====
The differential diagnosis of SRUS (and CCP) includes:<ref>{{cite book|last=al.]|first=senior editors, Bruce G. Wolff ... [et|title=The ASCRS textbook of colon and rectal surgery|year=2007|publisher=Springer|location=New York|isbn=0-387-24846-3}}</ref>
The histological appearance is as follows:
* [[polyps]]
* Segmental and superficial (shallow) ulceration.<ref name="Sadeghi2019" /><ref name="Alejandra2019" />
* [[endometriosis]]
* Obliteration of the lamina propria with fibromuscular / collagen infiltration.<ref name="Kuckelman2019" /><ref name="Sadeghi2019" /> This feature differentiates SRUS from [[inflammatory bowel disease]], and is the landmark diagnostic feature for SRUS.
* inflammatory [[granuloma]]s
* Hypertrophy and disruption of the muscularis mucosa layer.<ref name="Kuckelman2019" /><ref name="Sadeghi2019" />
* infectious disorders
* Hyperplasia and distortion of crypt structure.<ref name="Sadeghi2019" /><ref name="Alejandra2019" />
* drug-induced [[colitis]]
* Chronic inflammatory cell infiltration.<ref name="Alejandra2019" />
* mucus-producing [[adenocarcinoma]]
* No evidence of malignancy.<ref name="Kuckelman2019" /> Although, very rarely, the two conditions occur together).<ref name="Sadeghi2019" />


If the biopsy includes polypoid lesions, there are villiform structures visible.<ref name="Sadeghi2019" /> Gland entrapment in the submucosa is sometimes seen, which is termed [[colitis cystica profunda]].<ref name="Sadeghi2019" />
[[Defecography]], [[sigmoidoscopy]], transrectal [[ultrasound]], mucosal [[biopsy]], anorectal [[manometry]] and [[electromyography]] have all been used to diagnose and study SRUS.<ref name="abid" /><ref name="van" /> Some recommend biopsy as essential for diagnosis since ulcerations may not always be present, and others state [[defecography]] as the investigation of choice to diagnose SRUS.<ref name=mackle>{{cite journal|last=Mackle|first=EJ|coauthors=Parks, TG|title=The pathogenesis and pathophysiology of rectal prolapse and solitary rectal ulcer syndrome.|journal=Clinics in gastroenterology|date=1986 Oct|volume=15|issue=4|pages=985–1002|pmid=3536217}}</ref><ref name="levine" /><ref name="black" />


==Treatment==
==Management==
Treatment of SRUS is difficult and there is a lack of evidence-based guidelines.<ref name="Qari2020" /> The treatment is based on the pathophysiology of SRUS,<ref name="Sadeghi2019" /> and the main aim is restoration of a normal pattern of defecation.<ref name="Alejandra2019" /> The exact treatment depends on the severity of the symptoms, the severity/type of SRUS, and whether rectal prolapse is present or absent.<ref name="Sadeghi2019" />


Conservative measures are the first line treatment for patients with no symptoms or only mild to moderate symptoms, and those who have no significant anatomical defect.<ref name="Alejandra2019" /> Conservative measures by themselves may improve symptoms and prevent the condition getting worse.<ref name="Alejandra2019" /> Where conservative measures fail, or with severe disease and symptoms, or with significant anatomical defects, surgical options may be indicated.<ref name="Sadeghi2019" /><ref name="Alejandra2019" /> Improvement in symptoms does not always equate to healing of the ulcer as seen on endoscopy.<ref name="Sadeghi2019" />
Although SRUS is not a medically serious disease, it can be the cause of significantly reduced quality of life for patients. It is difficult to treat, and treatment is aimed at minimizing symptoms.


===Conservative (non-surgical)===
Stopping straining during bowel movements, by use of [[human defecation postures|correct posture]], [[dietary fiber]] intake (possibly included bulk forming [[laxatives]] such as [[psyllium]]), stool softeners (e.g. [[polyethylene glycol]],<ref>{{cite journal|last=Bishop|first=PR|coauthors=Nowicki, MJ|title=Nonsurgical Therapy for Solitary Rectal Ulcer Syndrome.|journal=Current treatment options in gastroenterology|date=2002 Jun|volume=5|issue=3|pages=215–223|pmid=12003716}}</ref><ref>{{cite journal|last=van den Brandt-Grädel|first=V|coauthors=Huibregtse, K; Tytgat, GN|title=Treatment of solitary rectal ulcer syndrome with high-fiber diet and abstention of straining at defecation.|journal=Digestive diseases and sciences|date=1984 Nov|volume=29|issue=11|pages=1005–8|pmid=6092015}}</ref> and [[biofeedback]] retraining to coordinate pelvic floor during defecation.<ref>{{cite journal|last=Jarrett|first=ME|coauthors=Emmanuel, AV; Vaizey, CJ; Kamm, MA|title=Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow.|journal=Gut|date=2004 Mar|volume=53|issue=3|pages=368–70|pmid=14960517}}</ref><ref>{{cite journal|last=Vaizey|first=CJ|coauthors=Roy, AJ; Kamm, MA|title=Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback.|journal=Gut|date=1997 Dec|volume=41|issue=6|pages=817–20|pmid=9462216}}</ref>
Conservative management is focused on education of the patient and behavioral modification. Where indicated, conservative management may also involve treatment of psychological problems,<ref name="Sadeghi2019" /> and avoidance of anoreceptive sex (to prevent trauma to the rectum).<ref name="Kuckelman2019" />


====Modification of bowel habit====
Surgery may be considered, but only if non surgical treatment has failed and the symptoms are severe enough to warrant the intervention. Improvement with surgery is about 55-60%.<ref>{{cite journal|last=Sitzler|first=PJ|coauthors=Kamm, MA; Nicholls, RJ; McKee, RF|title=Long-term clinical outcome of surgery for solitary rectal ulcer syndrome.|journal=The British journal of surgery|date=1998 Sep|volume=85|issue=9|pages=1246–50|pmid=9752869}}</ref>
* Regular bathroom visits,<ref name="Kuckelman2019" /> for a limited period of time.<ref name="Sadeghi2019" />
* Avoidance of excessive straining. This can improve symptoms in up to 67% of cases and allow some degree of healing of the ulcer in about 30% of cases.<ref name="Alejandra2019" />
* Use of a stool to elevate the legs during defecation,<ref name="Gouriou2018" /> thereby straightening the anorectal angle and allowing for less effort during defecation. Alternatively, a squatting position can be used.
* Avoidance of any kind of rectal manipulation (digitation, enemas, suppositories).<ref name="Alejandra2019" />


====Dietary measures====
Ulceration may persist even when symptoms resolve.<ref>{{cite journal|last=Vaizey|first=CJ|coauthors=van den Bogaerde, JB; Emmanuel, AV; Talbot, IC; Nicholls, RJ; Kamm, MA|title=Solitary rectal ulcer syndrome.|journal=The British journal of surgery|date=1998 Dec|volume=85|issue=12|pages=1617–23|pmid=9876062}}</ref>
* A high-[[fiber]] diet may help, but by itself is insufficient treatment. 30 to 40 grams of fiber per day has been advised.<ref name="Maluenda2024" /> Improvement with high-fiber diet varies between 19% and 70%.<ref name="Alejandra2019" />
* [[Bulk forming laxatives]],<ref name="Kuckelman2019" /> e.g. [[psyllium]] powder.<ref name="Qari2020" />
* [[Stool softener]]s.<ref name="Kuckelman2019" />
* Adequate intake of water (non-carbonated and caffeine-free drinks) during the day.<ref name="Sadeghi2019" />


== See also ==
====Biofeedback====
Biofeedback targets pelvic floor behaviors and enables a reprogramming of autonomic neurologic pathways associated with defecation.<ref name="Kuckelman2019" /> The treatment is particularly helpful for dyssynergic defecation (anismus). Research studies have shown that there is improved blood flow to the rectal mucosa after biofeedback therapy.<ref name="Alejandra2019" /> The overall rate of complete resolution of both symptoms and ulceration varies at 50-75%.<ref name="Kuckelman2019" /> Stool frequency and straining effort decrease after this treatment.<ref name="Alejandra2019" /> In about 56% of cases, biofeedback treatment stops rectal bleeding.<ref name="Alejandra2019" /> Some patients are able to cease relying on digitation.<ref name="Alejandra2019" /> Biofeedback is more effective in children with SRUS compared to adults.<ref name="Alejandra2019" />


A randomized controlled study compared topical agents (dexamethasone, sucralfate and bismuth) with biofeedback. Overall, biofeedback gave 80% improvements in evacuation difficulty, need for digitation, sensation of incomplete evacuation, evacuation time, and appearance of mucosa on colonoscopy compared to the topical agents (50% improvement).<ref name="Maluenda2024" /> However, the degree of long term improvement is not known.<ref name="Maluenda2024" />
* [[internal intussusception]]

* [[Rectal prolapse]]
====Topical agents====
* [[Mucosal prolapse]]
Several different topical treatments have been reported, with variable outcomes.<ref name="Alejandra2019" /> These are substances applied directly to the ulcer, usually administered by enema.<ref name="Kuckelman2019" /> They may be helpful for short term management of acute symptoms in SRUS.<ref name="Kuckelman2019" /> They are thought to work by reducing inflammation and physically forming a barrier over the surface of the ulcer to protect it from irritants, thereby allowing it to heal.<ref name="Qari2020" /><ref name="Sadeghi2019" /> However, the long term efficacy is unknown. According to a systematic review, 57% of SRUS patients who received medical treatment had resolution of ulceration.<ref name="Qari2020" /> Topical agents which have been used for SRUS include:
* [[tenesmus]]

* [[Rectal discharge]]
* [[Glucocorticoid]] steroids.<ref name="Alejandra2019" />
* [[outlet obstruction]]
* [[Sucralfate]].<ref name="Kuckelman2019" />
* [[rectal bleeding]]
* [[Salicylate]]s.<ref name="Alejandra2019" />
* [[Rectal malodor]]
* [[Sulfasalazine]].<ref name="Sadeghi2019" />
* [[Mesalamine]] (5-aminosalicylic acid).<ref name="Qari2020" /><ref name="Sadeghi2019" />

According to one report, topical agents had an efficacy between 28 and 90%. Sucralfate had a 45-81% resolution rate compared to sulfasalazine (30-64%) and combination of other topical agents (20-79%).<ref name="Maluenda2024" />

===Surgery===
Surgery may be indicated for severe cases of SRUS (either severe symptoms, severe ulceration, or significant associated anatomical defect such as prolapse), or when conservative measures fail.<ref name="Kuckelman2019" /><ref name="Sadeghi2019" /> Some authors state that most patients do not benefit from surgery.<ref name="Sadeghi2019" /> Overall, up to 33% of SRUS patients end up requiring surgery.<ref name="Kuckelman2019" /> A systematic review reported that SRUS improved in 77% of patients who underwent any type of surgery.<ref name="Gouriou2018" /> However, recurrence of the condition later developed in 52% of cases.<ref name="Gouriou2018" /> It has been suggested that any treatment which only addresses the ulcer without correcting the underlying causes will typically lead to recurrence.<ref name="Kuckelman2019" />

There are multiple different surgical procedures which have been reported for SRUS,<ref name="Sadeghi2019" /> including:
* Local excision (removing the area of ulceration).<ref name="Forootan2018" />
* Local therapies (usually injection of different agents into the rectal wall).<ref name="Kuckelman2019" />
* Delorme procedure.<ref name="Forootan2018" />
* Perineal proctectomy (Altemeier procedure).<ref name="Forootan2018" />
* Rectopexy.<ref name="Alejandra2019" />
* Stapled transanal local excision (STARR) (has been used for SRUS with internal prolapse).<ref name="Sadeghi2019" />
* Diversion colostomy.<ref name="Alejandra2019" />
* Transanal mucosal sleeve resection along with coloanal pull-through.<ref name="Forootan2018" />

====Local therapies====
Various local treatments for SRUS have been reported. According to one report, such measures have generally unfavorable results, and sometimes the ulcer returns deeper and larger than before the treatment.<ref name="Kuckelman2019" />

* Injection of steroid 100&nbsp;mg diluted in 10 ml water into the rectal wall around the ulcer.<ref name="Gouriou2018" />
* Argon plasma coagulation (APC). This procedure uses high frequency monopolar current directed by ionised argon gas to coagulate tissues and mucosal ulcers, aiming to promote healing through re-epithelializion.<ref name="Gouriou2018" />
* [[Sclerotherapy]]: injection into the submucosal layer or [[retro rectal space]] with 5% phenol, 30% hypertonic saline or 25% glucose and perianal [[cerclage]].<ref name="Sadeghi2019" />
* Human [[fibrin glue]] sealant applied endoscopically.<ref name="Sadeghi2019" /><ref name="Kuckelman2019" />
* Injection of [[botulinum toxin]] injection into the external anal sphincter,<ref name="Sadeghi2019" /><ref name="Kuckelman2019" /> (a treatment for dyssynergic defecation / anismus).

====Local excision====
Excision (removal) of the ulcer and suturing the resulting defect with surrounding healthy mucosa has been reported. However, there may not be any long-term benefit.<ref name="Kuckelman2019" /> Ulcers in the upper part of the rectum may be accessible to local excision using a transanal minimally invasive approach (TAMIS).<ref name="Kuckelman2019" /> Excision with [[Nd:YAG laser|neodymium yttrium-aluminium garnet laser]] has also been reported.<ref name="Gouriou2018" />

====Rectopexy====
{{main|Ventral rectopexy}}
Rectopexy is a surgery for rectal prolapse.<ref name="Forootan2018" /> A newer version of the procedure is termed ventral mesh rectopexy, which has also been used for SRUS.<ref name="Schlachta2018">{{cite book |last1=Schlachta |first1=CM |last2=Sylla |first2=P |title=Current Common Dilemmas in Colorectal Surgery |date=20 February 2018 |publisher=Springer |isbn=978-3-319-70117-2 |language=en}}</ref> It may be performed with or without anterior resection (removal of a portion of the front wall of the rectum).<ref name="Rao2020" /> A mesh may be used to reinforce the anterior rectal wall.<ref name="Kuckelman2019" /> It can be done as an open procedure or with a laparoscopic abdominal approach.<ref name="Kuckelman2019" />

Some authors state rectopexy is suitable in highly select cases,<ref name="Rao2020" /> while others say it is the procedure of choice,<ref name="George2016" /> since it directly addresses the most likely cause.<ref name="Kuckelman2019" /> There is not much evidence for the use of laparoscopic ventral rectopexy to treat SRUS,<ref name="Maluenda2024" /> but there is more evidence to support the its use compared to other surgical procedures.<ref name="Kuckelman2019" /> Approximately 55-83% of patients with SRUS get reduced symptoms after rectopexy,<ref name="Kuckelman2019" /> and these benefits appear to be long term.<ref name="Forootan2018" /> In one study, 11 people with SRUS underwent laparoscopic ventral rectopexy. All of the patients showed resolved symptoms and mucosal injury one year after the procedure. In the long term, 1 patient developed recurrence after 4 years, and the other 7 who were evaluated in the long term did not develop recurrence.<ref name="Maluenda2024" /> Another study combined laparoscopic ventral rectopexy and biofeedback for 48 patients with SRUS. In all cases there was healing of the mucosa 3 months after the procedure. In 65% of cases there was improvement in symptoms of obstructed defecation and in 45% of cases there was improved quality of life. The rate of recurrence was 4-8% after an average follow up time of 33 months.<ref name="Badrek-Amoudi2013">{{cite journal |last1=Badrek-Amoudi |first1=AH |last2=Roe |first2=T |last3=Mabey |first3=K |last4=Carter |first4=H |last5=Mills |first5=A |last6=Dixon |first6=AR |title=Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome: a cause for optimism? |journal=Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland |date=May 2013 |volume=15 |issue=5 |pages=575-81 |doi=10.1111/codi.12077 |pmid=23107777}}</ref>

====STARR====
The stapled transanal rectal resection (STARR) procedure has been used both as an alternative to ventral mesh rectopexy and as a secondary procedure when ventral mesh rectopexy failed to completely resolve the condition.<ref name="Evans2014">{{cite journal |last1=Evans |first1=C. |last2=Ong |first2=E. |last3=Jones |first3=O. M. |last4=Cunningham |first4=C. |last5=Lindsey |first5=I. |title=Laparoscopic ventral rectopexy is effective for solitary rectal ulcer syndrome when associated with rectal prolapse |journal=Colorectal Disease |date=March 2014 |volume=16 |issue=3 |doi=10.1111/codi.12502 |pmid=24678526}}</ref> In one study, STARR gave improvement in all cases where biofeedback had not worked.<ref name="Maluenda2024" /> In comparison with ventral mesh rectopexy, STARR may result in higher rates of bowel [[urgency]], recurrence and other complications, some of which may be serious.<ref name="Maluenda2024" />

====Other options====
The following "last resort" surgical procedures (which may have significant consequences) have been reported in severe, persistent or recurrent cases of SRUS:

* [[Lower anterior resection]] with coloanal anastomosis/reconstruction.<ref name="Kuckelman2019" />
* [[Stoma (medicine)|Fecal diversion]] (can be a temporary measure).<ref name="Alejandra2019" />

==Epidemiology==
The condition is relatively rare, but the exact prevalence is not known.<ref name="Forootan2018" /> Prevalence has been estimated as 1 in 100,000 people per year.<ref name="Forootan2018" /> SRUS can occur at any age, but it is most common in adults aged between 30-50.<ref name="Forootan2018" /> Males and females are affected almost equally,<ref name="Forootan2018" /> or females slightly more.<ref name="Alejandra2019" />

[[Misdiagnosis]] as [[inflammatory bowel disease]] (IBD) or [[rectal polyps]] may hide the true prevalence of SRUS.<ref name="Forootan2018">{{cite journal |last1=Forootan |first1=M |last2=Darvishi |first2=M |title=Solitary rectal ulcer syndrome: A systematic review. |journal=Medicine |date=May 2018 |volume=97 |issue=18 |pages=e0565 |doi=10.1097/MD.0000000000010565 |pmid=29718850 |pmc=6392642}}</ref>


==References==
==References==
{{reflist|2}}
{{reflist|refs=
<ref name="Qari2020">{{cite journal |last1=Qari |first1=Y |last2=Mosli |first2=M |title=A systematic review and meta-analysis of the efficacy of medical treatments for the management of solitary rectal ulcer syndrome. |journal=Saudi Journal of Gastroenterology |date=January 2020 |volume=26 |issue=1 |pages=4–12 |doi=10.4103/sjg.SJG_213_19 |pmid=31898642 |pmc=7045767 |doi-access=free }}</ref>
<ref name="Kumagai2021">{{cite journal |last1=Kumagai |first1=H |last2=Yokoyama |first2=K |last3=Sunada |first3=K |last4=Yamagata |first4=T |title=Solitary rectal ulcer syndrome: A Misleading term. |journal=Pediatrics International |date=June 2021 |volume=63 |issue=6 |pages=739–740 |doi=10.1111/ped.14587 |pmid=34142735|s2cid=235463337 }}</ref>
<ref name="Alejandra2019">{{cite book |last1=Alejandra |first1=A-B |last2=José María |first2=R-T |last3=Enrique |first3=CA |title=Anorectal Disorders |date=1 January 2019 |publisher=Academic Press |isbn=978-0-12-815346-8 |pages=227–236 |chapter-url=https://www.sciencedirect.com/science/article/pii/B9780128153468000187 |language=en |chapter=18 - Solitary Rectal Ulcer Syndrome}}</ref>
<ref name="Gouriou2018">{{cite journal |last1=Gouriou |first1=C |last2=Chambaz |first2=M |last3=Ropert |first3=A |last4=Bouguen |first4=G |last5=Desfourneaux |first5=V |last6=Siproudhis |first6=L |last7=Brochard |first7=C |title=A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018? |journal=International Journal of Colorectal Disease |date=December 2018 |volume=33 |issue=12 |pages=1647–1655 |doi=10.1007/s00384-018-3162-z |pmid=30206681|s2cid=52187439 }}</ref>
<ref name="Kuckelman2019">{{cite book |author1=Kuckelman J |author2=Johnson EK |title=Chapter in: Clinical algorithms in general surgery: a practical guide |date=2019 |publisher=Springer |location=Cham |isbn=9783319984971 |pages=269–274 |chapter=Solitary Rectal Ulcer Syndrome}}</ref>
<ref name="Sadeghi2019">{{cite journal |last1=Sadeghi |first1=A |last2=Biglari |first2=M |last3=Forootan |first3=M |last4=Adibi |first4=P |title=Solitary Rectal Ulcer Syndrome: A Narrative Review. |journal=Middle East Journal of Digestive Diseases |date=July 2019 |volume=11 |issue=3 |pages=129–134 |doi=10.15171/mejdd.2019.138 |pmid=31687110 |pmc=6819965}}</ref>
<ref name="Rao2020">{{cite journal |last1=Rao |first1=SSC |last2=Tetangco |first2=EP |title=Anorectal Disorders: An Update. |journal=Journal of Clinical Gastroenterology |date=August 2020 |volume=54 |issue=7 |pages=606–613 |doi=10.1097/MCG.0000000000001348 |pmid=32692116|s2cid=220670975 }}</ref>
}}


== External links ==
{{Digestive system diseases}}
{{Medical resources
| DiseasesDB = 33675
| ICD10 = {{ICD10|K|62|6}}
| ICD9 = <!-- {{ICD9|}} -->
| ICDO =
| OMIM =
| MedlinePlus =
| eMedicineSubj =
| eMedicineTopic =
| MeshID =
}}
{{Gastroenterology}}


[[Category:GI tract disorders]]
[[Category:Colorectal surgery]]
[[Category:Proctology]]
[[Category:Rectal diseases]]
[[Category:Rectum]]
[[Category:Gastroenterology]]
[[Category:Medicine articles needing expert attention]]

Latest revision as of 04:35, 6 January 2025

Solitary rectal ulcer syndrome
Other namesSolitary rectal ulcer
SpecialtyColorectal surgery

Solitary rectal ulcer syndrome (SRUS or SRU) is a chronic disorder of the rectal mucosa (the lining of the rectum).[1] Very often but not always it occurs in association with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation (anismus). Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases, various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.[2]

Signs and symptoms

[edit]

The signs and symptoms are variable, and in up to 25% of patients there may be no symptoms.[3] The most common signs and symptoms are bleeding, which can vary from minor to severe, rectal prolapse and incomplete evacuation (35%-76% of cases).[4] According to one report, constipation is present in about 55% of cases, but diarrhea is present in 20%–40% of cases.[1] Reported symptoms are:

Causes

[edit]

The exact cause is unclear and the condition is not fully understood.[3] There are thought to be multiple factors which simultaneously cause the condition.[3] Long term injury to the rectal mucosa and ischemic trauma are thought to be the main mechanisms.[5] In a report of 36 patients with SRUS, the underlying cause was internal prolapse (intussusception) in 20 patients, external rectal prolapse in 14 patients, and dyssynergic defecation (anismus) in 2 patients.[7]

Direct trauma

[edit]

Self-digitation is when individuals with constipation resort to inserting a finger into the rectum in order to "hook out" fecal pellets or to apply pressure to an obstructing lesion (see: obstructed defecation). The rectal mucosa is fragile and vulnerable to trauma when such manoeuvres are performed chronically. It is thought that this self-induced trauma is one possible mechanism of SRUS.[1] However, since sometimes the location of SRUS lesion(s) is much further than a finger could reach means that this cannot be the only cause.[5] In constipation, the stools may be very hard and this is another possible mechanism of trauma.[1]

Excessive straining: chronic constipation, dyssynergic defecation

[edit]

People with constipation or certain anatomical anomalies are more likely to end up using excessive straining during defecation attempts.[5] Prolonged straining may cause direct trauma to the rectal mucosa.[5] Most patients with SRUS have dyssynergic defecation (previously termed anismus).[8] This is a failure of relaxation (or paradoxical contraction) of the puborectalis muscle during defecation attempts. This pelvic floor muscle is normally supposed to relax, thereby straightening the anorectal angle and allowing rectal contents to be evacuated. Dyssynergic defecation causes high pressure in the rectum and in the anal canal,[1] which causes lengthening[1] and compression of the rectal tissues, which in turn leads to ischema of the mucosa.[8] There is also a shearing movement of the rectum against the pelvic floor muscles.[8] In the long term this leads to repeated mucosal damage.[8] Inappropriate contraction of puborectalis in the squatting position causes traumatic compression of the rectal wall against the anal canal.[5] Also, it is reported that individuals with SRUS have not only increased pressure when squeezing, but also higher resting pressure compared to normal controls.[5]

Rectal prolapse and ischemic injury

[edit]

SRUS is usually accompanied by prolapse (e.g. external prolapse or rectoanal intussusception/internal prolapse) or other pelvic-floor disorders.[1][7] This is association is common, but not always present.[9] Some state that if SRUS is not treated, it would always tend to progress to rectal prolapse.[5] The relationship of SRUS with rectal prolapse and rectal cystitis profunda is debated.[8] Some see SRUS and prolapse as synonymous, while others see them as separate entities,[8] and state that they do not share the same physiology.[6] For example, the mucosal changes that occur with external rectal prolapse can be separated from the mucosal changes seen in SRUS.[6]

The excessive pressure caused by straining (i.e. dyssynergic defecation and constipation) may in the long term lead to development of the spectrum of rectal prolapse conditions (mucosal versus full-thickness prolapse, internal versus external rectal prolapse).[5] These conditions create chronic vascular trauma (ischemia or hypoperfusion) in the rectal mucosa,[1] which predisposes it to ulceration,[8] and pressure necrosis.[4] Even the initial small areas of an intussusception can lead to vascular injury and reduce blood supply to the region.[5] This is the first stage of ulcer development.[5]

Other factors

[edit]

Psychological factors are also thought to be involved, since patients with SRUS sometimes have psychological disorders such as obsessive-compulsive disorder.[1] Also, some unknown factors may also be involved, such as hormonal factors related to pregnancy.[5] Other possible factors are rectal hypersensitivity,[4] and impaired rectal evacuation of stool.[9]

Diagnosis

[edit]

Diagnosis is difficult because of rarity of the condition and because of the variability of the symptoms and the histologic appearance.[1][5] The condition is sometimes misdiagnosed.[1] Clinicians may not be familiar with the condition, and treat for inflammatory bowel disease, or simple constipation.[10][11] Diagnosis may be delayed by many years as a result.[4]

Differential diagnosis

[edit]

The differential diagnosis is as follows:

Investigations

[edit]

Investigations used in the diagnosis of SRUS include defecography, endoanal ultrasound, colonoscopy and histological examination of a biopsy.[3]

Colonoscopy

[edit]

The macroscopic appearance of SRUS is very variable.[8] Indeed, the condition has been referred to as “the three-lies disease”,[4] because the name of the condition is sometimes misleading. In reality, there may be more than one lesion, which may not be ulcerative,[12] and the condition may appear in different parts of the gastrointestinal tract (i.e. other than the rectum).[3]

Classically, there is a solitary ulcer. But only 20% of patients have a single ulcer whereas in other cases there may be multiple lesions.[6] The size of the ulcers is usually 0.5–4 cm.[5] The lesion is most often located on the anterior (front) or lateral (side) rectal wall, centered on a rectal fold,[1] usually 10 cm from the anal verge.[8] Less commonly there may be ulcers in the anal canal or even in the sigmoid colon.[5] The nature of the tissue changes can vary from simple erythema (redness) / hyperaemia (increased blood flow) of the mucosa in 18% of cases,[1] to a chronic-appearing, small, shallow ulcer with nodular margins and a white or sloughing base.[8][1] In up to 33% of cases there is no ulceration but instead one or more well-developed polyps or mass lesions.[8][5] There is usually mild proctitis (inflammation of the rectal mucosa) surrounding the ulcer.[2]

Defecography

[edit]

Conventional defecography or magnetic resonance defecography may be used.[1] Between 50-100% of patients with SRUS will have abnormal defecography results.[5] Defecography findings in SRUS may include:

  • Evidence of dyssynergic defecation (anismus),[8] 82% of patients with SRUS had dssynergic defecation in one report.[1]
  • Rectal intussusception (the most common finding in one report).[5]
  • Anterior (front) or posterior (back) rectocele.[5]
  • Prolonged retention of contrast media.[5]
  • Megarectum.[5]

Endoanal ultrasound

[edit]

Endoanal ultrasound can determine the depth of the ulcer and the structure of the external and internal anal sphincters.[8] Endoanal ultrasound findings in SRUS include:

Anorectal manometry

[edit]

As a diagnostic investigation, anorectal manometry can evaluate defecation function. It can highlight excessive and prolonged straining effort during defecation attempts, and also record any improvement in function before and after treatment interventions.[13] It is uncommonly used to diagnose SRUS, although biofeedback is still commonly used as a treatment.

Biopsy

[edit]

The histological appearance is as follows:

  • Segmental and superficial (shallow) ulceration.[5][1]
  • Obliteration of the lamina propria with fibromuscular / collagen infiltration.[8][5] This feature differentiates SRUS from inflammatory bowel disease, and is the landmark diagnostic feature for SRUS.
  • Hypertrophy and disruption of the muscularis mucosa layer.[8][5]
  • Hyperplasia and distortion of crypt structure.[5][1]
  • Chronic inflammatory cell infiltration.[1]
  • No evidence of malignancy.[8] Although, very rarely, the two conditions occur together).[5]

If the biopsy includes polypoid lesions, there are villiform structures visible.[5] Gland entrapment in the submucosa is sometimes seen, which is termed colitis cystica profunda.[5]

Management

[edit]

Treatment of SRUS is difficult and there is a lack of evidence-based guidelines.[4] The treatment is based on the pathophysiology of SRUS,[5] and the main aim is restoration of a normal pattern of defecation.[1] The exact treatment depends on the severity of the symptoms, the severity/type of SRUS, and whether rectal prolapse is present or absent.[5]

Conservative measures are the first line treatment for patients with no symptoms or only mild to moderate symptoms, and those who have no significant anatomical defect.[1] Conservative measures by themselves may improve symptoms and prevent the condition getting worse.[1] Where conservative measures fail, or with severe disease and symptoms, or with significant anatomical defects, surgical options may be indicated.[5][1] Improvement in symptoms does not always equate to healing of the ulcer as seen on endoscopy.[5]

Conservative (non-surgical)

[edit]

Conservative management is focused on education of the patient and behavioral modification. Where indicated, conservative management may also involve treatment of psychological problems,[5] and avoidance of anoreceptive sex (to prevent trauma to the rectum).[8]

Modification of bowel habit

[edit]
  • Regular bathroom visits,[8] for a limited period of time.[5]
  • Avoidance of excessive straining. This can improve symptoms in up to 67% of cases and allow some degree of healing of the ulcer in about 30% of cases.[1]
  • Use of a stool to elevate the legs during defecation,[6] thereby straightening the anorectal angle and allowing for less effort during defecation. Alternatively, a squatting position can be used.
  • Avoidance of any kind of rectal manipulation (digitation, enemas, suppositories).[1]

Dietary measures

[edit]

Biofeedback

[edit]

Biofeedback targets pelvic floor behaviors and enables a reprogramming of autonomic neurologic pathways associated with defecation.[8] The treatment is particularly helpful for dyssynergic defecation (anismus). Research studies have shown that there is improved blood flow to the rectal mucosa after biofeedback therapy.[1] The overall rate of complete resolution of both symptoms and ulceration varies at 50-75%.[8] Stool frequency and straining effort decrease after this treatment.[1] In about 56% of cases, biofeedback treatment stops rectal bleeding.[1] Some patients are able to cease relying on digitation.[1] Biofeedback is more effective in children with SRUS compared to adults.[1]

A randomized controlled study compared topical agents (dexamethasone, sucralfate and bismuth) with biofeedback. Overall, biofeedback gave 80% improvements in evacuation difficulty, need for digitation, sensation of incomplete evacuation, evacuation time, and appearance of mucosa on colonoscopy compared to the topical agents (50% improvement).[13] However, the degree of long term improvement is not known.[13]

Topical agents

[edit]

Several different topical treatments have been reported, with variable outcomes.[1] These are substances applied directly to the ulcer, usually administered by enema.[8] They may be helpful for short term management of acute symptoms in SRUS.[8] They are thought to work by reducing inflammation and physically forming a barrier over the surface of the ulcer to protect it from irritants, thereby allowing it to heal.[4][5] However, the long term efficacy is unknown. According to a systematic review, 57% of SRUS patients who received medical treatment had resolution of ulceration.[4] Topical agents which have been used for SRUS include:

According to one report, topical agents had an efficacy between 28 and 90%. Sucralfate had a 45-81% resolution rate compared to sulfasalazine (30-64%) and combination of other topical agents (20-79%).[13]

Surgery

[edit]

Surgery may be indicated for severe cases of SRUS (either severe symptoms, severe ulceration, or significant associated anatomical defect such as prolapse), or when conservative measures fail.[8][5] Some authors state that most patients do not benefit from surgery.[5] Overall, up to 33% of SRUS patients end up requiring surgery.[8] A systematic review reported that SRUS improved in 77% of patients who underwent any type of surgery.[6] However, recurrence of the condition later developed in 52% of cases.[6] It has been suggested that any treatment which only addresses the ulcer without correcting the underlying causes will typically lead to recurrence.[8]

There are multiple different surgical procedures which have been reported for SRUS,[5] including:

  • Local excision (removing the area of ulceration).[3]
  • Local therapies (usually injection of different agents into the rectal wall).[8]
  • Delorme procedure.[3]
  • Perineal proctectomy (Altemeier procedure).[3]
  • Rectopexy.[1]
  • Stapled transanal local excision (STARR) (has been used for SRUS with internal prolapse).[5]
  • Diversion colostomy.[1]
  • Transanal mucosal sleeve resection along with coloanal pull-through.[3]

Local therapies

[edit]

Various local treatments for SRUS have been reported. According to one report, such measures have generally unfavorable results, and sometimes the ulcer returns deeper and larger than before the treatment.[8]

  • Injection of steroid 100 mg diluted in 10 ml water into the rectal wall around the ulcer.[6]
  • Argon plasma coagulation (APC). This procedure uses high frequency monopolar current directed by ionised argon gas to coagulate tissues and mucosal ulcers, aiming to promote healing through re-epithelializion.[6]
  • Sclerotherapy: injection into the submucosal layer or retro rectal space with 5% phenol, 30% hypertonic saline or 25% glucose and perianal cerclage.[5]
  • Human fibrin glue sealant applied endoscopically.[5][8]
  • Injection of botulinum toxin injection into the external anal sphincter,[5][8] (a treatment for dyssynergic defecation / anismus).

Local excision

[edit]

Excision (removal) of the ulcer and suturing the resulting defect with surrounding healthy mucosa has been reported. However, there may not be any long-term benefit.[8] Ulcers in the upper part of the rectum may be accessible to local excision using a transanal minimally invasive approach (TAMIS).[8] Excision with neodymium yttrium-aluminium garnet laser has also been reported.[6]

Rectopexy

[edit]
Main article: Ventral rectopexy

Rectopexy is a surgery for rectal prolapse.[3] A newer version of the procedure is termed ventral mesh rectopexy, which has also been used for SRUS.[14] It may be performed with or without anterior resection (removal of a portion of the front wall of the rectum).[9] A mesh may be used to reinforce the anterior rectal wall.[8] It can be done as an open procedure or with a laparoscopic abdominal approach.[8]

Some authors state rectopexy is suitable in highly select cases,[9] while others say it is the procedure of choice,[7] since it directly addresses the most likely cause.[8] There is not much evidence for the use of laparoscopic ventral rectopexy to treat SRUS,[13] but there is more evidence to support the its use compared to other surgical procedures.[8] Approximately 55-83% of patients with SRUS get reduced symptoms after rectopexy,[8] and these benefits appear to be long term.[3] In one study, 11 people with SRUS underwent laparoscopic ventral rectopexy. All of the patients showed resolved symptoms and mucosal injury one year after the procedure. In the long term, 1 patient developed recurrence after 4 years, and the other 7 who were evaluated in the long term did not develop recurrence.[13] Another study combined laparoscopic ventral rectopexy and biofeedback for 48 patients with SRUS. In all cases there was healing of the mucosa 3 months after the procedure. In 65% of cases there was improvement in symptoms of obstructed defecation and in 45% of cases there was improved quality of life. The rate of recurrence was 4-8% after an average follow up time of 33 months.[15]

STARR

[edit]

The stapled transanal rectal resection (STARR) procedure has been used both as an alternative to ventral mesh rectopexy and as a secondary procedure when ventral mesh rectopexy failed to completely resolve the condition.[16] In one study, STARR gave improvement in all cases where biofeedback had not worked.[13] In comparison with ventral mesh rectopexy, STARR may result in higher rates of bowel urgency, recurrence and other complications, some of which may be serious.[13]

Other options

[edit]

The following "last resort" surgical procedures (which may have significant consequences) have been reported in severe, persistent or recurrent cases of SRUS:

Epidemiology

[edit]

The condition is relatively rare, but the exact prevalence is not known.[3] Prevalence has been estimated as 1 in 100,000 people per year.[3] SRUS can occur at any age, but it is most common in adults aged between 30-50.[3] Males and females are affected almost equally,[3] or females slightly more.[1]

Misdiagnosis as inflammatory bowel disease (IBD) or rectal polyps may hide the true prevalence of SRUS.[3]

References

[edit]
  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az Alejandra, A-B; José María, R-T; Enrique, CA (1 January 2019). "18 - Solitary Rectal Ulcer Syndrome". Anorectal Disorders. Academic Press. pp. 227–236. ISBN 978-0-12-815346-8.
  2. ^ a b Herold A, Lehur PA, Matzel KE, O'Connell PR (2017). European Manual of Medicine: Coloproctology (Second ed.). Berlin, Germany. ISBN 978-3-662-53210-2.{{cite book}}: CS1 maint: location missing publisher (link)
  3. ^ a b c d e f g h i j k l m n o p q r s t u v w x y Forootan, M; Darvishi, M (May 2018). "Solitary rectal ulcer syndrome: A systematic review". Medicine. 97 (18): e0565. doi:10.1097/MD.0000000000010565. PMC 6392642. PMID 29718850.
  4. ^ a b c d e f g h i j Qari, Y; Mosli, M (January 2020). "A systematic review and meta-analysis of the efficacy of medical treatments for the management of solitary rectal ulcer syndrome". Saudi Journal of Gastroenterology. 26 (1): 4–12. doi:10.4103/sjg.SJG_213_19. PMC 7045767. PMID 31898642.
  5. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az Sadeghi, A; Biglari, M; Forootan, M; Adibi, P (July 2019). "Solitary Rectal Ulcer Syndrome: A Narrative Review". Middle East Journal of Digestive Diseases. 11 (3): 129–134. doi:10.15171/mejdd.2019.138. PMC 6819965. PMID 31687110.
  6. ^ a b c d e f g h i j k l Gouriou, C; Chambaz, M; Ropert, A; Bouguen, G; Desfourneaux, V; Siproudhis, L; Brochard, C (December 2018). "A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018?". International Journal of Colorectal Disease. 33 (12): 1647–1655. doi:10.1007/s00384-018-3162-z. PMID 30206681. S2CID 52187439.
  7. ^ a b c George B, Guy R, Jones O, Vogel J (2 May 2016). Colorectal Surgery: Clinical Care and Management. Chichester, West Sussex, UK: John Wiley & Sons. ISBN 978-1-118-67478-9.
  8. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an Kuckelman J; Johnson EK (2019). "Solitary Rectal Ulcer Syndrome". Chapter in: Clinical algorithms in general surgery: a practical guide. Cham: Springer. pp. 269–274. ISBN 9783319984971.
  9. ^ a b c d Rao, SSC; Tetangco, EP (August 2020). "Anorectal Disorders: An Update". Journal of Clinical Gastroenterology. 54 (7): 606–613. doi:10.1097/MCG.0000000000001348. PMID 32692116. S2CID 220670975.
  10. ^ Blackburn C, McDermott M, Bourke B (February 2012). "Clinical presentation of and outcome for solitary rectal ulcer syndrome in children". Journal of Pediatric Gastroenterology and Nutrition. 54 (2): 263–265. doi:10.1097/MPG.0b013e31823014c0. PMID 22266488. S2CID 27955947.
  11. ^ Umar SB, Efron JE, Heigh RI (September 2008). "An interesting case of mistaken identity". Case Reports in Gastroenterology. 2 (3): 308–313. doi:10.1159/000154816. PMC 3075189. PMID 21490861.
  12. ^ Kumagai, H; Yokoyama, K; Sunada, K; Yamagata, T (June 2021). "Solitary rectal ulcer syndrome: A Misleading term". Pediatrics International. 63 (6): 739–740. doi:10.1111/ped.14587. PMID 34142735. S2CID 235463337.
  13. ^ a b c d e f g h i Maluenda A, V; Baeza I, P; Martínez M, M; Iriarte C, MJ; Bonomo M, C; Rojas A, J; Narváez J, C (February 2024). "[What we know today about solitary rectal ulcer syndrome]". Revista medica de Chile. 152 (2): 225–234. doi:10.4067/s0034-98872024000200225. PMID 39450799.
  14. ^ Schlachta, CM; Sylla, P (20 February 2018). Current Common Dilemmas in Colorectal Surgery. Springer. ISBN 978-3-319-70117-2.
  15. ^ Badrek-Amoudi, AH; Roe, T; Mabey, K; Carter, H; Mills, A; Dixon, AR (May 2013). "Laparoscopic ventral mesh rectopexy in the management of solitary rectal ulcer syndrome: a cause for optimism?". Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 15 (5): 575–81. doi:10.1111/codi.12077. PMID 23107777.
  16. ^ Evans, C.; Ong, E.; Jones, O. M.; Cunningham, C.; Lindsey, I. (March 2014). "Laparoscopic ventral rectopexy is effective for solitary rectal ulcer syndrome when associated with rectal prolapse". Colorectal Disease. 16 (3). doi:10.1111/codi.12502. PMID 24678526.
[edit]
Retrieved from "https://en.wikipedia.org/enwiki/w/index.php?title=Solitary_rectal_ulcer_syndrome&oldid=1267676090"