Rectal Ulcer, Solitary

• • 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

Symptoms and Signs

• • 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

Imaging Findings

• • 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

• • Neoplasm

  • Stricture

  • Rectal prolapse

  • Rectal intussusception

  • Nonrelaxing puborectalis muscle

  • Diverticular disease

  • Colitis cystica profunda

  • Crohn colitis

Rule Out

• • Neoplasm

• • 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

• • 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

Surgery

Indications

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

Contraindications

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

Medications

• • Dietary fiber, bulking agents

Complications

• • Rarely, life-threatening hemorrhage

Prognosis

• • 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%