Solitary Rectal Ulcer (SRUS)

Definition
- Rare chronic benign disorder characterized by a combination of symptoms, clinical findings, and histologic abnormalities.
Prevalence
- 20% of patients have a single ulcer.
- 40% of patients have multiple ulcers.
- Remaining patients have nonspecific lesions (e.g., hyperemic mucosa or pseudopolyps).
Demographics
- Affects young adults (30–40 years).
- Slight female predominance.
Etiology (Cause)
- Multifactorial:
  - Internal rectal prolapse.
  - Abnormal/paradoxical contraction of the puborectalis muscle.
- Leads to trauma and compression of the anterior rectal wall during defecation, causing mucosal ischemia and ulceration.
Symptoms
- Rectal bleeding.
- Prolonged excessive straining.
- Incomplete defecation/tenesmus.
- Mucous discharge.
- Perineal and abdominal pain.
- Constipation.
- Up to 25% of patients are asymptomatic.
Physical Examination Findings
- Intrarectal prolapse.
- 1 to 1.5-cm ulcer on the anterior rectal wall, located 3 to 10 cm from the anal verge.
- Sometimes difficult to differentiate from rectal cancer.
Histologic Findings
- Fibromuscular obliteration of the lamina propria.
- Hypertrophied muscularis mucosae with muscular fibers between crypts.
- Glandular crypt abnormalities.
- Differentiates SRUS from rectal cancer, IBD, ischemic colitis, and infectious proctitis.
Management
- Mild to moderate symptoms:
  - Patient education and behavioral modification:
    - High-fiber diet.
    - Stool softeners and bulking laxatives.
    - Avoidance of straining/anal digitations.
    - Minimize time on the toilet.
    - Sucralfate, corticosteroid, and/or mesalamine enemas.
- Severe cases: (Surgery is rarely indicated)
  - Surgical options for highly symptomatic, non-responsive patients:
    - Local excision of the ulcer.
    - Treatment of rectal prolapse.
    - Defunctioning stoma for patients who have failed other treatments.
Prognosis
- Many patients continue to experience symptoms of anorectal dysfunction despite treatment.