Solitary Rectal Ulcer Syndrome

DEFINITION
Condition characterized by difficult evacuation, rectal bleeding, pain and mucus discharge.
... often there is no detectable ulcer, and when there is, ulcers may be multiple.
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EPIDEMIOLOGY
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AETIOLOGY

Pathogenesis
See below

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BIOLOGICAL BEHAVIOUR

Pathophysiology

Despite the name, ulcers are not always seen on proctoscopy
And may be multiple.

Traditional theory
Difficult evacuation --> straining + self instrumentation --> rectal trauma, bleeding and ulcer.

Updated views
Still not entirely clear
But rectal intussusception and outlet obstrtion a factor.
- defectography often demonstrates obstruction.
Anorectal testing not required.
Pelvic dyssynergia in 82%
- less relxation, lower threshold for first sensation, reduce desire to defecate and urge.
- balloon expulsion times prolonged.
Dynaic MRI shows:
- lack of mesorectosacral fixation, with anorectal redundancy and pelvic floor descent.
Hence an underlying problem and not just the ulcer requires treatment.

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MANIFESTATIONS

Symptoms

Prolonged time on toilet
Incomplete evacuation
Excessive straining
Digitations to evacuate stool

Proctoscopy
Often ulcer is on anterior wall but can be anywhere.
Us. 5-10 cm form anus

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INVESTIGATIONS

Biopsy
Critical to rule out cancer.
Distinct histology:
- fibromuscular obliteration of lamina propria
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MANAGEMENT

Approach
Frequent misdiagnoses and presentation delay.
Begin Rx with conservative therapy
- heal ulcer, manage bleeding, relieve pain.
Consider Surgery if this fails.

Non-Surgical

1. Diet
Fiber, fluids, stool softeners.

2. Topical
Enemas of steroids, sulfasalzine, sucralfate are not useful long term.
But, particularly sucralfate, provide short term relief.

3. Biofeedback
Addresses underlying disorder; good short term results.
Every 1-2 weeks, for 4-5 sessions.
Practice expelling balloon with electromyographic feedback.
Good short term gain (~2/3s benefit), but falls to 33% over time.

Surgery

Severe or refractory problems
Or associated problems eg prolapse or bleeding requiring Tx
Use conservative measures above as adjuncts.
Local excision --> poor healing and outcomes.
Consider combined rectal tissue resection and rectopexy.
- with rectopexy alone, often get constipation.
Low anterior resection is an alternative option.
- but higher morbidity, so reserved.
- also colostomy.
Bottom line: rectopexy and rectosigmoid resection is probably preferrable for best long-term outcome.

STARR Procedure?
- removes redundant tissue and case series suggest good outcomes
- but experimental at this point.

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REFERENCES
Cameron 10th