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  • • Obliteration of rectal lamina propria by fibroblasts

    • Term "solitary rectal ulcer" misnomer as patients may present with no ulcer, single or multiple ulcers, or polypoid lesions

    • May be clinically associated and caused by pelvic floor abnormalities such as rectal prolapse, intussusception

    • Results in defecation disorder with intense straining

    • Possible etiology: Ischemic insult or trauma to rectal mucosa

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Symptoms and Signs

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  • • Difficulty in initiating bowel movements

    • May be associated with rectal prolapse

    • Fecal incontinence

    • Sense of rectal fullness

    • Tenesmus

    • Sense of incomplete evacuation

    • Patients may resort to regular to extensive use of enemas, suppositories

    • Pain on defecation

    • Passage of mucus and blood per rectum

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Imaging Findings

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  • Proctoscopy

    • -Most lesions located anterior and anterolateral quadrants of rectal wall 10-12 cm above anal verge

      -Ulcers may solitary, multiple, circumferential, usually shallow

      -Mucosa erythematous, edematous

    Defecography: May reveal inappropriate puborectalis contraction during straining

    Electromyography: Evidence of pudendal neuropathy

    Anal manometry: Decreased resting and squeezing pressure; increased rectal sensitivity and reaction to balloon distention

    Endorectal US: Increased diameter of internal anal sphincter; rectal wall muscle hypertrophy

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  • • Neoplasm

    • Stricture

    • Rectal prolapse

    • Rectal intussusception

    • Nonrelaxing puborectalis muscle

    • Diverticular disease

    • Colitis cystica profunda

    • Crohn colitis

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Rule Out

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  • • Neoplasm

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  • • History and physical exam (if necessary, patient can be observed while straining on commode to evaluate for rectal prolapse)

    • Rule out malignancy

    • Sigmoidoscopy or colonoscopy

    • Defecography

    • Electromyography

    • Anal manometry

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  • • After ruling out malignancy, patients should be reassured

    • Treatment options range from dietary modification to biofeedback, rectopexy, coloanal anastomosis, diverting colostomy

    • Therapy based on severity of symptoms and associated diseases

    • Asymptomatic patients in whom solitary rectal ulcer was found during screening or work-up for an unrelated disease, should be monitored expectantly with dietary fiber and bulking agents

    • Dietary modification

    • -Increase daily fiber intake to 30-40 g

      -Increase fluid intake

      -Avoid caffeine and alcoholic beverages

    • Bowel habit modifications

    • -Spend less time on commode

      -Avoid excessive straining

    • Pelvic floor retraining: Biofeedback techniques (balloon expulsion exercises) and psychological counseling

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Surgery

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Indications

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  • • Pelvic floor pathologies (evidence on defecography) such as rectal prolapse should undergo repair of prolapse (perineal proctectomy or rectopexy)

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Contraindications

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  • • Lack of anatomic pelvic floor pathology (prolapse/intussusception)

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Medications

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  • • Dietary fiber, bulking agents

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Complications

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  • • Rarely, life-threatening hemorrhage

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Prognosis

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  • • Combination of dietary and bowel habit modification results in reasonable relief in 60-70%

    • After operation, recurrence of prolapse and solitary rectal ulcer over 20 years is ~ 13%

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References

• Mollen RM ...

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