Solitary rectal ulcer syndrome: clinical features, pathophysiology, diagnosis and treatment strategies

Abstract

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disease, characterized by a combination of symptoms, clinical findings and histological abnormalities. Ulcers are only found in 40% of the patients; 20% of the patients have a solitary ulcer, and the rest of the lesions vary in shape and size, from hyperemic mucosa to broad-based polypoid. Men and women are affected equally, with a small predominance in women. SRUS has also been described in children and in the geriatric population. Clinical features include rectal bleeding, copious mucus discharge, prolonged excessive straining, perineal and abdominal pain, feeling of incomplete defecation, constipation, and rarely, rectal prolapse. This disease has well-described histopathological features such as obliteration of the lamina propria by fibrosis and smooth muscle fibers extending from a thickened muscularis mucosa to the lumen. Diffuse collage deposition in the lamina propria and abnormal smooth muscle fiber extensions are sensitive markers for differentiating SRUS from other conditions. However, the etiology remains obscure, and the condition is frequently associated with pelvic floor disorders. SRUS is difficult to treat, and various treatment strategies have been advocated, ranging from conservative management to a variety of surgical procedures. The aim of the present review is to summarize the clinical features, pathophysiology, diagnostic methods and treatment strategies associated with SRUS.

Keywords: Clinical characteristics; Diagnosis; Pathophysiology; Solitary rectal ulcer syndrome; Treatment.

Figure 1

Endoscopic imaging and corresponding histological findings in solitary rectal ulcer syndrome patients. A: Colonoscopy revealed localized yellowish slough, rectal edema, erythema, and superficial ulcerations; B: Histology (hematoxylin and eosin) shows smooth muscle hyperplasia in the lamina propria between colonic glands, and surface ulceration with associated chronic inflammatory infiltrates. Magnification: × 40 (left), × 100 (right).

Figure 2

Suggested algorithm for treatment strategies in patients with solitary rectal ulcer syndrome. SRUS: Solitary rectal ulcer syndrome.