Solitary rectal ulcer syndrome

The signs and symptoms are variable, and in up to 25% of patients there may be no symptoms. The most common signs and symptoms are bleeding, which can vary from minor to severe, rectal prolapse and incomplete evacuation (35%-76% of cases). According to one report, constipation is present in about 55% of cases, but diarrhea is present in 20%–40% of cases. Reported symptoms are: • Hematochezia (lower gastrointestinal bleeding / rectal bleeding), which can vary from minor to severe. • Rectal pain. • Pelvic discomfort. • Tenesmus. • Sensation of incomplete evacuation of stool. • Mucous rectal discharge (Mucorrhea). • Constipation, which may be chronic and severe. • Straining during defecation. • Rectal prolapse or other pelvic floor disorders. • Repeated use of laxatives. • Fecal incontinence. • Diarrhea. ==Causes==

The exact cause is unclear and the condition is not fully understood. This association is common, but not always present. Some state that if SRUS is not treated, it would always tend to progress to rectal prolapse. The relationship of SRUS with rectal prolapse and rectal cystitis profunda is debated. Some see SRUS and prolapse as synonymous, while others see them as separate entities, and state that they do not share the same physiology. For example, the mucosal changes that occur with external rectal prolapse can be separated from the mucosal changes seen in SRUS. The excessive pressure caused by straining (i.e. dyssynergic defecation and constipation) may in the long term lead to development of the spectrum of rectal prolapse conditions (mucosal versus full-thickness prolapse, internal versus external rectal prolapse). These conditions create chronic vascular trauma (ischemia or hypoperfusion) in the rectal mucosa, which predisposes it to ulceration, and pressure necrosis. Even the initial small areas of an intussusception can lead to vascular injury and reduce blood supply to the region. This is the first stage of ulcer development. Other factors Psychological factors are also thought to be involved, since patients with SRUS sometimes have psychological disorders such as obsessive-compulsive disorder. Also, some unknown factors may also be involved, such as hormonal factors related to pregnancy. Other possible factors are rectal hypersensitivity, and impaired rectal evacuation of stool. ==Diagnosis==

Diagnosis is difficult because of rarity of the condition and because of the variability of the symptoms and the histologic appearance. Diagnosis may be delayed by many years as a result. and the condition may appear in different parts of the gastrointestinal tract (i.e. other than the rectum). Defecography Conventional defecography or magnetic resonance defecography may be used. It is uncommonly used to diagnose SRUS, although biofeedback is still commonly used as a treatment. Biopsy The histological appearance is as follows: • Segmental and superficial (shallow) ulceration. • Obliteration of the lamina propria with fibromuscular / collagen infiltration. This feature differentiates SRUS from inflammatory bowel disease, and is the landmark diagnostic feature for SRUS. • Hypertrophy and disruption of the muscularis mucosa layer. • Hyperplasia and distortion of crypt structure. • Chronic inflammatory cell infiltration. • No evidence of malignancy. Although, very rarely, the two conditions occur together. If the biopsy includes polypoid lesions, there are villiform structures visible. Gland entrapment in the submucosa is sometimes seen, which is termed colitis cystica profunda. ==Management==

Treatment of SRUS is difficult and there is a lack of evidence-based guidelines. It may be performed with or without anterior resection (removal of a portion of the front wall of the rectum). STARR The stapled transanal rectal resection (STARR) procedure has been used both as an alternative to ventral mesh rectopexy and as a secondary procedure when ventral mesh rectopexy failed to completely resolve the condition. In one study, STARR gave improvement in all cases where biofeedback had not worked. In comparison with ventral mesh rectopexy, STARR may result in higher rates of bowel urgency, recurrence and other complications, some of which may be serious. Other options The following "last resort" surgical procedures (which may have significant consequences) have been reported in severe, persistent or recurrent cases of SRUS: • Lower anterior resection with coloanal anastomosis/reconstruction. • Fecal diversion (can be a temporary measure). ==Epidemiology==

The condition is relatively rare, but the exact prevalence is not known. ==References==