Treatment of Solitary Rectal Ulcer Syndrome (SRUS)
Biofeedback therapy is the most effective treatment for solitary rectal ulcer syndrome, particularly in patients with dyssynergic defecation, with studies showing ulcer healing rates of up to 90% when dyssynergia is successfully corrected. 1
Understanding SRUS
- SRUS is a benign condition characterized by rectal ulceration, often associated with dyssynergic defecation and rectal prolapse 2
- Differential diagnoses that must be excluded include infection, irritable bowel syndrome, Crohn's disease, ulcerative colitis, chemical colitis, and rectal prolapse 3
- Proximal constipation is common in SRUS and may contribute to symptoms and poor response to therapy 4
Treatment Algorithm
First-Line Therapy: Conservative Management
- Begin with patient education about the benign nature of the condition 2
- Implement dietary fiber supplementation and bowel retraining to establish regular defecation patterns 2
- Treat proximal constipation with stool bulking agents or laxatives if present 4
Second-Line Therapy: Topical Treatments
- Topical mesalamine (5-ASA) suppositories (1g daily) are recommended for patients with rectal inflammation 4
- For patients intolerant to mesalamine, topical corticosteroid suppositories (e.g., prednisolone 5mg) can be used 4
- Consider sucralfate enemas for 6 weeks if symptoms persist despite other measures 2
Third-Line Therapy: Biofeedback
- Biofeedback therapy should be prioritized for patients with confirmed dyssynergic defecation 1
- Studies show that ulcers heal in up to 90% of patients whose dyssynergic defecation pattern resolves after biofeedback 1
- Long-term follow-up studies demonstrate that approximately half of patients maintain clinical benefit at 3 years 5
- Biofeedback works by training patients to relax pelvic floor muscles during straining and restore normal coordination 3
Fourth-Line Therapy: Surgical Options
- Surgery should be considered only after failure of conservative and biofeedback approaches 6
- Rectopexy or Delorme's procedure offer the best success rates for patients with rectal prolapse 2
- Combining surgery with biofeedback therapy results in lower recurrence rates compared to surgery alone 7
Special Considerations
- Diagnostic testing should include defecography to assess for inappropriate puborectalis contraction and occult rectal mucosal prolapse in refractory cases 2
- Anorectal manometry can help identify dyssynergic defecation patterns that would benefit from biofeedback 1
- Reduction in anal resting pressure after biofeedback therapy correlates with improved healing rates 1
Common Pitfalls to Avoid
- Failure to identify and treat underlying dyssynergic defecation 1
- Premature progression to surgical intervention before adequate trials of conservative therapy and biofeedback 6
- Inadequate duration of biofeedback therapy (most successful protocols involve an average of 12 sessions) 1
- Not addressing proximal constipation, which can contribute to persistent symptoms 4