Solitary Rectal Ulcer Syndrome

A 34-year-old woman who has had constipation and episodes of obstipation for at least 5 years recently passed blood and mucus rectally and has a rectal prolapse. Colonoscopy revealed an ulcer on the anterior rectal wall, approximately 4 cm from the anus.

This is a case of solitary rectal ulcer syndrome, a chronic, benign condition consisting of single or multiple lesions surrounded by a hyperemic margin. The lesions may be ulcerated or polypoid and usually occur on the anterior or anterolateral rectal wall.

The syndrome, which is associated with rectal prolapse, probably results from repeated trauma of the rectal mucosa against the contraction of the puborectal muscle. Other causes include ischemic bowel disease, self-inflicted trauma, ulceration from suppositories, and congenital hamartomatous malformations.

Patients often present with rectal bleeding, tenesmus, and straining with defecation. The diagnosis is made by sigmoidoscopy and histologic examination of biopsy specimens. Typically, the lesion is an ulcer with a white base surrounded by erythema; polypoid lesions are seen in 25% of cases, and granular or hyperemic mucosa without ulceration occurs in 18%. The histologic picture of the rectal mucosa, as seen here, shows a lamina propia filled with fibroblasts and muscle fibers. There is also an excess of mucosal collagen.

Treatment is usually conservative and involves a high-fiber diet. Under certain circumstances, excisional surgery may be considered, but its therapeutic role is controversial because of the high recurrence rate. Drs Christine Chang, Scott Goldstein, and Kim Cuesta of Philadelphia write that the patient discussed here was given a high-fiber diet and will undergo routine sigmoidoscopy every 3 to 5 years.