What is the treatment for solitary rectal ulcer syndrome?

Treatment of Solitary Rectal Ulcer Syndrome (SRUS)

Conservative therapy with dietary fiber, bowel retraining, and bulk laxatives should be the first-line treatment for solitary rectal ulcer syndrome, with more advanced therapies reserved for refractory cases. 1

Initial Diagnosis and Assessment

• SRUS is a rare benign rectal disorder characterized by rectal bleeding, mucorrhoea, excessive straining during defecation, tenesmus, feeling of incomplete defecation, and constipation 2
• Diagnosis requires histological confirmation with the major feature being fibromuscular obliteration of the lamina propria 2
• Before initiating treatment, it's essential to exclude other conditions that may cause similar symptoms, including inflammatory bowel disease, colorectal neoplasia, and infectious causes 3
• Defecography should be performed in persistent cases to assess for inappropriate puborectalis contraction and occult rectal mucosal prolapse 1

Treatment Algorithm

First-Line Treatment

• High-fiber diet and abstention from straining during defecation - shown to achieve complete healing in approximately 71% of patients within an average of 10.5 months 4
• Bulk laxatives to soften stools and normalize defecation habits 1, 2
• Patient education about the benign nature of the condition and proper toilet habits 2
• Regular toilet habits and avoiding prolonged sitting on the toilet 2

Second-Line Treatment

• Sucralfate enemas for 6 weeks for patients who fail to respond to conservative measures 1
• Topical treatments similar to those used for distal ulcerative colitis may be considered, such as:
  • Topical mesalamine for patients with rectal inflammation (similar to treatment principles for distal colitis) 5
  • Topical corticosteroids for those intolerant to topical mesalamine 5

Third-Line Treatment

• Biofeedback therapy for patients with documented inappropriate puborectalis contraction 1, 2
• Argon plasma coagulation (APC) for refractory cases - shown to achieve complete healing in 76.3% of patients who failed conventional treatment 6

Surgical Options

• Reserved for patients with documented rectal mucosal prolapse who fail medical management 1
• Rectopexy or Delorme's procedure offer the best success rates, but surgical choice should be based on surgeon experience and patient preference 1
• Surgical consultation should be considered only after failure of all conservative approaches 1

Important Considerations

• Complete "cures" are uncommon in SRUS; realistic treatment goals should focus on symptom reduction rather than complete resolution 1
• Treatment must be individualized based on the underlying pathophysiologic mechanism (straining, rectal prolapse, dyssynergic defecation) 3
• SRUS may overlap with dyssynergic defecation syndrome, health anxiety disorder, and obsessive-compulsive disorder, requiring a composite treatment approach 3
• Proximal constipation is common and may contribute to symptoms and poor response to therapy, similar to what is observed in refractory distal colitis 5
• Regular follow-up is essential to assess treatment response and adjust therapy accordingly 1

Treatment Outcomes

• With conservative therapy alone (high-fiber diet and proper defecation habits), complete healing can be achieved in up to 71% of patients 4
• For refractory cases, APC has shown promising results with 76.3% of patients achieving complete healing of ulcers 6
• Patients should be reassured that the condition is benign, as anxiety about the diagnosis can perpetuate symptoms 1, 3