Solitary Rectal Ulcer

Solitary rectal ulcer syndrome is a benign disorder of the rectum caused by repetitive trauma, ischaemia and mucosal prolapse, producing a solitary or multiple ulcers, polypoid lesions or erythematous mucosa.

• It affects mainly young adults (20 to 40 years), women slightly more than men, but also children.
• Pathogenesis: excessive straining, paradoxical puborectalis contraction, internal intussusception or prolapse, digital evacuation or manipulation, and mucosal ischaemia.
• Only about 40 percent have a true ulcer; the rest have polypoid or flat erythematous patches.

Rectal bleeding (fresh blood), mucus discharge, tenesmus, perianal or rectal pain, sensation of incomplete evacuation, prolonged straining, constipation or diarrhoea, and digital evacuation.

• Ulcers lie on the anterior or anterolateral wall 5 to 10 cm from the anal verge, are shallow with a white slough and surrounding erythema.
• Differential diagnosis: Crohn disease, ulcerative proctitis, ischaemic proctitis, infectious proctitis, rectal adenocarcinoma, lymphoma, endometriosis, colitis cystica profunda, radiation proctopathy, rectal polyps, amoebiasis, tuberculosis.
• Complications: bleeding and anaemia, stricture, perforation (rare), colitis cystica profunda, chronic pain, faecal incontinence and psychological distress.

Proctoscopy and flexible sigmoidoscopy show ulcer, polypoid lesion or erythema.

• Biopsy: fibromuscular obliteration of the lamina propria, crypt distortion, and mucosal thickening are diagnostic features; exclude dysplasia and malignancy.
• Defecography (barium or MR) shows rectal intussusception or prolapse, and anorectal manometry shows dyssynergia.
• Endoanal ultrasound or MRI to assess the rectal wall; stool tests, tuberculosis and amoeba testing in endemic areas.

Supportive: counselling and avoidance of straining; behavioural modification and toilet training; fibre 25 to 30 g daily (psyllium 1 tablespoon twice daily) and fluids; stop digital manipulation.

Pharmacological

• Osmotic laxative: macrogol 17 g daily or lactulose 15 to 30 mL twice daily.
• Topical therapy: sucralfate enema 2 g in 20 mL twice daily for 8 weeks; mesalazine enema 1 g nightly for 4 to 8 weeks or mesalazine suppository 1 g nightly; hydrocortisone retention enema 100 mg nightly for 2 weeks.
• Sulfasalazine 1 g twice daily for refractory cases.
• Fibrin glue, argon plasma coagulation or botulinum toxin A in refractory cases.

Procedures

• Biofeedback therapy (6 to 8 sessions) for dyssynergia: ulcer healing in about 40 to 60 percent and symptom improvement in 60 to 80 percent.
• Surgery for failed conservative care or complete prolapse: laparoscopic ventral mesh rectopexy, perineal rectosigmoidectomy, Delorme procedure, local excision (low success), diverting stoma for refractory disease.

Special groups: children (conservative therapy, behaviour), HIV (exclude opportunistic infection), pregnancy (conservative).

Red flags: heavy bleeding, ulcer with mass, weight loss, perforation, stricture, non-healing ulcer.

Follow-up: flexible sigmoidoscopy at 8 to 12 weeks to document healing; repeat biopsy for persistent ulcers.