Background

• Solitary rectal ulcer syndrome (SRUS) is a relatively uncommon condition that affects the rectum, the lower part of the large intestine leading to the anus. It is characterized by the presence of either a single ulcer or multiple ulcers in the rectal mucosa, which is the inner lining of the rectum.
• While SRUS is generally considered a non-malignant disorder, it can give rise to a range of symptoms and complications that significantly impact an individual’s quality of life.

Epidemiology

• Prevalence: SRUS is considered a rare condition with a relatively low prevalence. The exact prevalence rates may vary among different studies and populations. Reported prevalence ranges from 0.4 to 12.4 cases per 100,000 population. It is more frequently observed in women, with a female-to-male ratio of approximately 2:1. 
• Age of Onset: Although SRUS can affect individuals of all ages, it is most diagnosed in adults between 30 and 50 years old. However, it can also occur in children, typically between the ages of 2 and 10, although less frequently. 
• Associated Conditions: SRUS is often associated with underlying conditions that contribute to its development. The most reported associated conditions include chronic constipation, prolonged straining during defecation, rectal prolapse, and disorders affecting the pelvic floor muscles. Other less frequent associations include inflammatory bowel disease, irritable bowel syndrome, and prior anorectal surgery. 

Anatomy

Pathophysiology

• Chronic trauma and ischemia: It can result from prolonged and repeated straining during bowel movements, constipation, excessive use of enemas, or digital manipulation. These actions can cause ongoing mechanical trauma to the rectal mucosa, disrupting the normal blood supply and leading to reduced blood flow (ischemia). This ischemia can, in turn, contribute to the formation of ulcers. 
• Abnormal rectal motility: It is frequently observed in patients with SRUS. These motility issues can include the inability to relax the internal anal sphincter, contracting the pelvic floor muscles when attempting to defecate, and altered coordination of rectal muscle contractions. These disturbances in rectal motility contribute to increased tension and straining on the rectal wall, ultimately causing damage to the mucosal lining. 
• Rectal prolapse: The protrusion of the rectum through the anus, has been associated with SRUS. This condition can lead to chronic stretching and trauma to the rectal mucosa, resulting in the development of ulcers. 
• Impaired mucosal barrier: The rectal mucosa normally acts as a protective barrier against harmful substances and bacteria. However, in individuals with SRUS, the mucosal barrier function may be impaired, making the rectal mucosa more vulnerable to injury and ulcer formation. 

Etiology

• Chronic constipation: Chronic constipation is considered one of the main predisposing factors for SRUS. The repeated straining during defecation and the passage of hard stools may lead to trauma and injury to the rectal mucosa, eventually resulting in the formation of ulcers. 
• Rectal prolapse: Rectal prolapse, a condition in which the rectum protrudes through the anus, has been associated with SRUS. The constant friction and pressure exerted on the rectal mucosa during the prolapse can cause ulceration. 
• Abnormal rectal motility: Some studies suggest that abnormal rectal motility, including increased resting tone or spasm of the rectal muscles, may contribute to the development of SRUS. These abnormalities can disrupt the normal blood supply to the rectal mucosa, leading to ulcer formation. 
• Ischemia: Ischemia, which refers to inadequate blood supply to a particular area, has been proposed as a potential cause of SRUS. Reduced blood flow to the rectal mucosa may impair its healing and make it more susceptible to ulceration. 
• Trauma: Trauma to the rectal mucosa, either from digital manipulation during defecation or from the use of enemas or rectal instruments, has been implicated in the development of SRUS. 
• Psychological factors: Psychological elements, including stress, anxiety, and depression, have been proposed as influential factors in the development of SRUS. These factors may contribute to altered rectal sensation and abnormal rectal motility, which can predispose individuals to the development of ulcers. 

Genetics

Prognostic Factors

• Age: SRUS commonly affects individuals between the ages of 20 and 50. Younger patients may have a better prognosis due to their overall better healing capacity and response to treatment. 
• Duration of symptoms: The length of time an individual has experienced symptoms of SRUS can impact the prognosis. Early diagnosis and prompt treatment initiation may lead to better outcomes. 
• Severity of symptoms: The severity of SRUS symptoms, such as rectal bleeding, mucous discharge, and pain, can vary from mild to severe. More severe symptoms may suggest a more extensive disease process and could indicate a potentially more challenging prognosis. 
• Response to treatment: The response to various treatment modalities, such as dietary modifications, fiber supplementation, topical therapies, biofeedback, or surgical intervention, can influence the prognosis. Patients who respond well to treatment and achieve symptom resolution have a more favorable prognosis. 

Clinical History

Age Group: Solitary rectal ulcer syndrome (SRUS) is a rare condition that primarily affects adults. It is more commonly observed in individuals between the ages of 20 and 50 years old. However, SRUS can occur in people of any age group, including children and older adults, although it is less frequently seen in these populations. The condition is more prevalent in females than males.  

Physical Examination

• Digital rectal examination (DRE): This is a standard procedure in which the healthcare provider inserts a gloved, lubricated finger into the rectum to assess the rectal tone, presence of masses or ulcers, and any signs of tenderness or pain. They may also check for rectal prolapse or evidence of rectal mucosal abnormalities. 
• Proctoscopy or anoscopy: These procedures involve the use of a specialized instrument to examine the rectum and anal canal. Proctoscopy utilizes a longer tube called a proctoscope, while anoscopy uses a shorter tube called an anoscope. These tools allow the healthcare provider to visualize the rectal mucosa and identify any ulcers, polyps, or other abnormalities. 
• Sigmoidoscopy or colonoscopy: If necessary, a healthcare provider may recommend a more extensive examination of the colon and rectum using a sigmoidoscope or colonoscope. 
• Biopsy: During a sigmoidoscopy or colonoscopy, the healthcare provider may perform a biopsy, which involves taking small tissue samples from the rectal ulcers. These samples are sent to a laboratory for further analysis to confirm the diagnosis of SRUS and rule out other conditions. 

Age group

Associated comorbidity

• Chronic constipation: SRUS is commonly seen in individuals with a history of chronic constipation. The repeated straining and difficulty in passing stools can lead to increased pressure on the rectal wall, contributing to the development of rectal ulcers. 
• Inflammatory bowel disease (IBD): While SRUS is considered a separate entity from IBD, there have been reports of SRUS occurring in individuals with underlying ulcerative colitis or Crohn’s disease. It is unclear whether SRUS is a direct consequence of IBD or an independent condition that coincidentally coexists. 
• Psychiatric disorders: Psychological factors, particularly stress and psychiatric disorders like depression and anxiety, have been associated with SRUS. It is believed that these factors may influence bowel habits and rectal muscle function, contributing to the development or exacerbation of SRUS. 

Associated activity

Acuity of presentation

• Symptoms: The symptoms of SRUS can range from mild to severe, and the acuity of presentation refers to how quickly and intensely these symptoms manifest. Common symptoms include rectal bleeding (often bright red blood), rectal pain, difficulty passing stools, a feeling of incomplete evacuation, and mucus discharge. The acuity of presentation may involve sudden onset or a gradual progression of these symptoms. 
• Ulcer characteristics: The acuity of the ulcer itself can vary. In some cases, the ulcer may be superficial and small, while in others, it can be deep and extensive. Acute presentation may involve a larger or more prominent ulcer, which may be associated with increased pain or bleeding. 
• Frequency and duration of symptoms: The acuity of SRUS can also be influenced by the frequency and duration of symptoms. Some individuals may experience intermittent symptoms, while others may have persistent or worsening symptoms over time. 

Differential Diagnoses

• Inflammatory bowel disease (IBD): Conditions such as Crohn’s disease and ulcerative colitis can cause ulcers in the rectum. Clinical features, including diarrhea, abdominal pain, and systemic symptoms, are typically more prominent in IBD compared to SRUS. Endoscopic and histological evaluation can help differentiate between the two. 
• Infectious proctitis: Infections, such as sexually transmitted infections (e.g., gonorrhea, chlamydia) or other bacterial or viral infections, can cause rectal ulcers. Evaluation may include specific tests for infectious agents, and symptoms may include discharge, pain, or a history of high-risk sexual behavior. 
• Ischemic proctitis: Reduced blood flow to the rectum due to vascular diseases, such as atherosclerosis or thromboembolic events, can lead to rectal ulcers. Risk factors like advanced age, diabetes, or cardiovascular disease may be present. Vascular imaging and clinical evaluation are important for diagnosis. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Fiber supplementation: Increasing your intake of dietary fiber or using fiber supplements can aid in softening the stool and promoting regular bowel movements, thus reducing the need for straining while defecating. This can be particularly advantageous for individuals with persistent constipation. 
• Laxatives: If constipation is a contributing factor, healthcare professionals may prescribe laxatives to alleviate symptoms and prevent straining. Various types of laxatives, such as bulk-forming agents, osmotic laxatives, or stimulant laxatives, may be recommended based on individual requirements. 
• Topical therapies: Local treatments, including rectal suppositories or enemas containing mesalamine, corticosteroids, or sucralfate, can be utilized to directly target ulcers and facilitate healing. These medications aid in reducing inflammation and promoting tissue repair. 
• Biofeedback therapy: Biofeedback therapy can be beneficial for patients with abnormal defecation dynamics or pelvic floor dysfunction. This technique involves the use of specialized sensors to provide feedback on muscle activity during bowel movements, enabling patients to learn how to relax and coordinate their pelvic floor muscles more effectively. 
• Surgical intervention: In cases where conservative measures fail to alleviate symptoms or if complications arise, surgery may be considered. Surgical options, such as rectal advancement flap, rectopexy, or sphincterotomy, may be recommended based on the specific circumstances and the expertise of the healthcare provider. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-therapy-for-modifying-the-environment

• Increase fiber intake: Consuming an adequate amount of dietary fiber can help regulate bowel movements and prevent constipation, which can worsen SRUS symptoms. it is important to incorporate a variety of fruits, vegetables, whole grains, and legumes into your meals. Gradually increase your fiber intake to avoid sudden changes that may cause discomfort. 
• Stay hydrated: It is crucial to maintain proper hydration to support regular bowel movements and prevent constipation. It is recommended to consume a minimum of eight glasses of water daily. It is advisable to moderate the intake of caffeinated and alcoholic beverages to avoid excessive consumption.  
• Limit trigger foods: Certain foods can irritate the digestive system and potentially worsen SRUS symptoms. These trigger foods vary among individuals, so it’s essential to identify and avoid any that seem to exacerbate your symptoms. Common trigger foods include spicy foods, greasy/fried foods, caffeine, alcohol, and carbonated beverages. 

behavior-therapy

Biofeedback: Biofeedback is a technique that helps individuals become more aware of their body’s physiological responses and learn to control them. In the case of SRUS, biofeedback can be used to train the individual to improve the coordination and strength of the rectal muscles. This can help in restoring normal bowel movements and reducing symptoms.

avoidance-of-straining

• Straining during bowel movements can further damage the rectal tissues in individuals with SRUS.
• It’s important to establish regular bowel habits and avoid excessive straining.
• This can be achieved by following a high-fiber diet, drinking enough water, and avoiding constipation. 

Use of Topical treatment in improvement of symptoms

• Sucralfate: Sucralfate is a medication that forms a protective barrier over ulcers or irritated areas in the gastrointestinal tract. It works by binding to the ulcer site and creating a physical barrier against stomach acid and other irritants. It may also be considered for SRUS to provide a protective effect on rectal ulcers. However, the evidence supporting its efficacy specifically for SRUS is limited. 
• Salicylate: Salicylate medications, such as mesalazine or sulfasalazine, are often prescribed for inflammatory bowel diseases like ulcerative colitis. While SRUS shares some similarities with inflammatory bowel diseases, it is not classified as one. These medications can help reduce inflammation and promote healing of rectal ulcers. However, further research is needed to establish their effectiveness specifically for SRUS. 

Use of corticosteroid and sulfasalazine enemas in ulcer healing

• Corticosteroids, such as hydrocortisone or prednisolone, possess potent anti-inflammatory properties. In the context of SRUS, corticosteroid enemas can be employed to reduce rectal inflammation and promote ulcer healing. The enema form allows for direct application of the medication to the affected area. Corticosteroid enemas are usually used for a short duration, typically two to four weeks, to minimize the risk of systemic side effects associated with long-term corticosteroid use. 
• sulfasalazine enemas are not a standard treatment for SRUS, they may be considered as an alternative therapy in refractory cases or when other treatment options have failed. Sulfasalazine enemas work by exerting an anti-inflammatory effect locally in the rectum, like corticosteroid enemas. 

Use of botulinum toxin injection in treating rectal ulcer

• Botulinum toxin helps to relax the rectal muscles, reducing excessive contractions and spasms that contribute to the formation and persistence of the rectal ulcer. 
• By reducing muscle spasms and easing tension in the rectal area, botulinum toxin injections can help alleviate pain and discomfort associated with SRUS. 

surgery

• Surgical intervention is considered in rare cases where conservative measures and other interventions fail to provide relief. In severe cases, surgical alternatives might involve the partial elimination of the rectal lining, known as partial-thickness resection, or the complete removal of the rectum, referred to as proctectomy. 
• Surgical intervention, including perineal proctectomy, is generally reserved for individuals with SRUS who have failed to respond to conservative treatments or who have developed complications such as refractory bleeding or persistent symptoms.  
• Proctectomy: It is generally reserved for severe cases of SRUS that are unresponsive to conservative measures and other treatments. It involves the complete removal of the rectum and may be performed in conjunction with the creation of a permanent colostomy or ileoanal pouch-anal anastomosis, depending on the individual’s specific condition and overall health. 

Medication

Future Trends

Media Gallary

References

• Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis and treatment strategies – PMC (nih.gov) 
• Solitary rectal ulcer syndrome: physiology and treatment options – PubMed (nih.gov)