From the Research
The most appropriate initial management for a patient with a solitary rectal ulcer 6-7 cm from the anal verge with benign histology but significant bleeding is conservative management with stool softeners, high-fiber diet, and avoidance of straining during defecation, along with topical treatments such as sucralfate enemas, as supported by the study 1 published in 2021. This approach is favored due to its less invasive nature and the potential to address the underlying pathophysiology, which often involves mucosal trauma from straining or prolapse. The use of sucralfate enemas, in particular, has been shown to be effective in promoting ulcer healing, as demonstrated in the study 2. Other options, such as biofeedback, may also be considered, especially given the association between solitary rectal ulcer syndrome and dyssynergic defecation, as discussed in the study 3. For persistent bleeding, endoscopic treatments like argon plasma coagulation, injection therapy with epinephrine, or application of hemostatic clips can be considered, with the choice depending on the severity of bleeding and the patient's overall condition, as outlined in the systematic review 4. Surgical options, including transanal excision of the ulcer or rectopexy, are typically reserved for cases that do not respond to conservative management or are associated with rectal prolapse, as noted in the study 5. Regular follow-up with repeat endoscopy is crucial to monitor healing and exclude malignant transformation, even in cases with initially benign biopsies. Key considerations in the management of solitary rectal ulcer syndrome include:
- Addressing the underlying pathophysiology, such as mucosal trauma from straining or prolapse
- Initial conservative management with dietary changes and topical treatments
- Consideration of biofeedback for dyssynergic defecation
- Endoscopic treatments for persistent bleeding
- Surgical options for refractory cases or those with rectal prolapse
- Regular follow-up to monitor healing and exclude malignant transformation.