Solitary Rectal Ulcer Syndrome

Solitary rectal ulcer syndrome is a rare syndrome associated with evacuation dysfunction.7 The underlying patho-physiology involves paradoxical contraction, instead of relaxation, of the muscles of the pelvic floor during defecation. Consequently, patients strain against immobile, contracted muscles of the pelvic floor impeding the passage of stool. Chronic straining may lead to ischemia and ulceration of the anterior rectal wall. Classic symptoms include significant time straining, feeling of incomplete emptying, rectal bleeding, passage of mucous, anorectal pain, tenesmus, and the need for digital assistance for evacuation.

Clinical history and sigmoidoscopic findings, including single or multiple ulcers or hyperemia without ulceration, establish a diagnosis of SRUS. Ulcers are often shallow with gray-white base and zone of hyperemia. In addition, polypoid lesions may develop and must be differentiated from adenomatous polyps on histology. The lesions can be confused with benign and malignant neoplasms, or localized areas of inflammatory bowel disease, radiation proctitis, and pseudomembranous colitis. Biopsy is mandatory and confirms diagnosis. Histologic changes include mucosal thickening, edema of the lamina propria, fibrosis, and architectural derangement of the muscularis propria with extension of the smooth muscle fibers into the glandular crypts. Colitis cystica profunda is a related disorder in which the symptoms are indistinguishable from SRUS. Instead of ulcerations,examination reveals firm nodules on the anterior rectal wall. Histologically, these nodules are composed of normal colonic glands located submucosally and filled with pools of mucus. The displacement of glands into the submucosa can be misdiagnosed as invasive carcinoma if note is not made of the histologically benign mucosa overlying the glands.

Anorectal physiology studies may reveal paradoxical puborectalis contraction but this finding is not necessary to make the diagnosis and may be found independent of the signs and symptoms of SRUS. Internal intussusception is found in 80% of patients with SRUS but is also found in normal volunteers undergoing defecography.

Solitary rectal ulcer syndrome is notorious for its chronicity and refractory nature to treatment. No single treatment is entirely satisfactory and therefore the main goal is to adjust patient symptoms and resolve bleeding. Once the diagnosis is established, all patients should undergo a trial of medical management. Initial treatment consists of fiber and hydration maintenance to aid in retraining the bowel and promoting normal motility; topical agents such as steroid or Carafate enemas have a limited role because they do not address the underlying pathophysiology. Judicious use of laxatives and enemas facilitate evacuation with minimal straining.

The mainstay of treatment of SRUS is behavioral techniques (biofeedback) directed at retraining pelvic floor coordination. In addition, the patient is taught posturing and appropriate use of abdominal musculature to minimize straining. Biofeedback also teaches patients to restrict the number of visits to the toilet, the duration of these visits, digitations, laxative use, and, most importantly, psychological support. The psychological effects are most evident in the short-term improvement of symptoms with the ability to resume normal employment despite nonhealing of the ulcer on sigmoidoscopic examination.8 Unlike surgery, it is noninvasive and free of side effects. Beneficial results deteriorate over time with only half of the patients maintaining benefits more than 36 months.9 However, repeat courses of biofeedback therapy reestablish success with behavioral modification.

Surgical therapies that have been described for SRUS include local excision, rectopexy, rectal mucosectomy (Delorme's procedure), proctectomy, colostomy, and argon beam coagulation. Local excision is not recommended because it does not address the underlying etiology and the lesions tend to recur. However, it may be useful to excise the lesion if malignancy cannot be excluded. Results of the other surgical modalities are variable and recurrence rates are high because dysfunction of the pelvic floor remains problematic.

In one study of 13 patients followed for 57 months, Marchal et al.10 found that simple resection did not improve symptoms, colostomy resolved the symptoms and healed the ulcer, and rectopexy and modified Delorme's procedures were prone to relapse of symptoms and ulcers. The authors concluded that considering the high failure rate of surgery, operative management should only be performed in patients with total rectal prolapse or intractable symptoms not amenable to behavioral therapy. In another study of 66 patients who underwent surgery for rectal prolapse and followed for 90 months, 22 of 49 patients who underwent rectopexy failed.11 Four of these patients underwent subsequent proctectomy with coloanal anastomosis of which three also failed, signifying the refractory nature of this disease process to surgical intervention. Ultimately, 14 patients required a stoma. Four of nine patients who underwent Delorme's procedure for the initial operation also failed. Four of seven patients who underwent anterior resection as the initial procedure underwent stoma creation. Overall, the stoma rate was 30%. Anterior resection used as a salvage procedure was not successful. Anti-prolapse operations only result in satisfactory long-term outcome in approximately 60% of patients with SRUS. These conclusions are not surprising because surgery does not tend to address the underlying dysfunction or abnormal motility of the rectum and pelvic floor. Consequently, symptom recurrence often persists and ulcer recurrence remains problematic. In those patients who undergo surgery, biofeedback is an important adjunct to retrain the muscles of the pelvic floor to prevent recurrence of the symptoms and the ulcer.

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