Treatment of Solitary Rectal Ulcer Syndrome
Begin with conservative management consisting of high-fiber diet, bowel retraining, and cessation of straining, followed by biofeedback therapy if symptoms persist—this stepwise approach achieves symptom resolution or improvement in approximately 60-70% of patients and should be exhausted before considering surgical intervention. 1, 2, 3
Initial Conservative Management (First-Line)
- Implement dietary fiber supplementation and bulk laxatives to soften stools and reduce mechanical trauma to the rectal mucosa 1, 2
- Instruct patients to completely avoid straining during defecation and normalize bowel habits, as chronic mechanical and ischemic trauma from hard stools is the primary pathogenic mechanism 2
- Provide patient reassurance that solitary rectal ulcer syndrome is a benign condition, as complete macroscopic healing is uncommon and symptom control should be the realistic therapeutic goal 1
- This conservative approach alone achieved complete ulcer healing and symptom resolution in 71% (15/21) of patients over an average of 10.5 months (range 2.5-21 months) 2
Second-Line Therapy: Sucralfate Enemas
- If symptoms persist after 4-8 weeks of conservative management, initiate sucralfate enemas for a 6-week trial 1
- Patients who respond should continue conservative therapy alongside the enemas 1
Third-Line Therapy: Biofeedback
- For patients failing conservative measures and sucralfate, perform defecography to assess for inappropriate puborectalis contraction and occult rectal mucosal prolapse 1
- Biofeedback retraining should be the primary treatment for patients with pelvic floor dyssynergia (inappropriate puborectalis contraction during defecation) 1, 4, 3
- In a prospective study, biofeedback achieved symptom elimination in 4/13 patients (31%) and improvement in an additional 4/13 patients (31%), for a total response rate of 62% 3
- Specific improvements with biofeedback include: reduced straining (7/13 patients), decreased need for digital evacuation (7/11 patients), reduced laxative use (5/9 patients), decreased toilet time (median 30 minutes reduced to 10 minutes), and fewer daily toilet visits (6 reduced to 3) 3
- Employment capacity improved significantly, with only 3/13 patients able to work before treatment compared to 8/13 after biofeedback 3
- Important caveat: Complete ulcer healing did not occur in any of the 9 patients examined after biofeedback, though the ulcer improved in 4 patients—this reinforces that symptom control, not complete healing, is the realistic goal 3
Surgical Intervention (Last Resort)
- Reserve surgery only for patients who fail all conservative measures and biofeedback, or those with documented full-thickness rectal prolapse 1, 5, 4
- Rectopexy or Delorme's procedure offer the best surgical success rates, though outcomes remain suboptimal 1
- Thoroughly discuss risks, benefits, and modest success rates before any surgical procedure, as previous surgery failed in 5/13 patients in one series 1, 3
- A reluctance to proceed to surgery is warranted given the superior outcomes with conservative management 4
Critical Pitfalls to Avoid
- Do not pursue aggressive surgical intervention early—the evidence strongly supports exhausting conservative and biofeedback options first, as surgery has poor outcomes and high failure rates 1, 4, 3
- Do not expect complete ulcer healing as the endpoint—focus on symptom control and functional improvement, as macroscopic healing is uncommon even with successful treatment 1, 3
- Do not misdiagnose as inflammatory bowel disease or rectal polyps—always obtain histologic confirmation before initiating treatment 1, 5
- Ensure defecography is performed before biofeedback to identify the specific pelvic floor dysfunction pattern and guide therapy 1