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home - Colon - Anal Diseases - Solitary Rectal Ulcer Syndrome Written by Dr Sebastian Zeki
Knowledge

Understands the clinical anatomy of the rectum and anus
Knows the causes of rectal bleeding and the methods of investigation
to determine the cause

Has awareness of the range of perianal conditions (which includes
abscesses and fistula), their clinical presentation and their
complications

Knows the techniques of investigation and the possible medical and
surgical treatments

Is aware of the treatment options for radiation proctitis
Skills
Take a history and appropriately examines the anus and rectum
Refers the patient for the appropriate endoscopic and radiological
investigations

Behaviours
Manages patients with anorectal disease in a sympathetic manner,
recognising and addressing the concerns caused by such conditions

Solitary Rectal Ulcer Syndrome

Solitary rectal ulcer syndrome Puborectalis Rectal prolapse Prolapsed rectal mucosa is forced downward during defaecatory pressureShear forces on the rectal mucosa caused by the paradoxical contraction of the puborectalis muscle can lead to ischaemia and ulceration Histological features:A thickened mucosal layer with distortion of the crypt architecture. The lamina propria is replaced with smooth muscle and collagen leading to hypertrophy and disorganization of the muscularis mucosa (= "fibromuscular obliteration") Symptoms:Rectal bleeding (56 %).Straining (28 %).Pelvic fullness (23 %).Mucous discharge, incontinence, tenesmus, and pain were less frequent. Endoscopic features: The lesion is usually on the anterior rectal wall within10 cm of the anal verge.The lesion can include mucosal ulcerations, poly-poid and mass lesions, or erythema alone. Treatment:Conservative treatment (For mild symptoms + no rectal prolapse).Stool bulking agents and biofeedback constipation management to prevent paradoxical puborectalis contraction.Topical corticosteroids, salicylates, sucralfate enemas, and biofeedback has been described but experience is limited.Surgery-for full-thickness or mucosal rectal prolapse, or with symptoms unresponsive to conservative management.Local excision or suturing of the lesions.Rectopexy.-Fecal diversion if all else fails Prevalence: 1 in 100,000; Av age: 48yrs; M=F Surgical options: Radiological studies — Transrectal and endoanal USS show a thickening of the rectal wall and internal anal sphincter.Endoanal USS can also show a loss of planes of the mucosa and muscu-laris propria.Defecation proctography can show a rectal prolapse +/- incomplete or delayed rectal emptying. Written by Dr Sebastian Zeki

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