Solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome (SRUS), also known as solitary ulcer of the rectum or mucosal prolapse syndrome of the rectum, is an uncommon benign chronic disorder affecting the rectum. Despite its name, the condition does not always present as a single ulcer — patients may have multiple ulcers, a polypoid lesion, or simply a patch of reddened rectal mucosa without a discrete ulcer. The condition is thought to arise primarily from chronic straining during defecation, internal rectal prolapse (intussusception), and direct trauma to the rectal mucosa. Paradoxical contraction of the pelvic floor muscles during defecation may also play a role, leading to high intrarectal pressures and ischemic injury to the rectal wall. The hallmark symptoms include rectal bleeding (often with passage of mucus), straining at stool, a sensation of incomplete evacuation, and rectal pain or discomfort. Some patients experience constipation, while others may have diarrhea. In more advanced cases, rectal prolapse may be evident. The ulcers are most commonly found on the anterior rectal wall, typically 5 to 10 centimeters from the anal verge. Diagnosis is confirmed by endoscopy and characteristic histopathological findings, which include fibromuscular obliteration of the lamina propria, thickening of the muscularis mucosae, and surface ulceration or erosion. These histological features are important because SRUS can be misdiagnosed as inflammatory bowel disease or even rectal malignancy. Treatment is primarily conservative and includes behavioral modifications such as increasing dietary fiber intake, adequate hydration, avoidance of excessive straining, and biofeedback therapy to retrain pelvic floor muscles. Topical treatments including sucralfate enemas and corticosteroid preparations have been used with variable success. In refractory cases, particularly those associated with significant rectal prolapse, surgical intervention such as rectopexy may be considered. The condition tends to be chronic and relapsing, and complete resolution can be difficult to achieve. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, and pelvic floor physiotherapists often yields the best outcomes.

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