Nonsurgical therapy for solitary rectal ulcer syndrome
- 49 Downloads
The treatment of solitary rectal ulcer syndrome (SRUS) remains problematic and is less than ideal. Prospective, well-designed studies assessing the efficacy of treatment for SRUS are few; most of the knowledge imparted for treating SRUS is experiential. As such, firm treatment recommendations can not be made. Rather, a conservative, stepwise, individualized approach must be employed. Diagnostic modalities should be incorporated in the management scheme to direct treatment when indicated.
Management must include patient reassurance that the underlying lesion is benign, because complete “cures” are uncommon in those with SRUS. The goals of therapy should be discussed with the patient prior to initiating treatment. Although the ultimate goal is macroscopic and microscopic healing, a realistic goal is cessation or minimization of symptoms.
We outline a reasonable approach to the management of SRUS. Histologic confirmation of SRUS should prompt a discussion of the presumed pathogenic mechanisms with the patient. Conservative therapy with dietary fiber, bowel retraining, and bulk laxatives should be employed. If symptoms persist, the patient should receive a trial of sucralfate enemas for 6 weeks. Individuals who respond should continue conservative therapy. However, if symptoms persist, defecography can be done to assess for inappropriate puborectalis contraction and occult rectal mucosal prolapse. Patients with inappropriate contraction of the puborectalis can be offered biofeedback. Patients with occult rectal mucosal prolapse can be considered for surgery. However, the risks, benefits, and success rates of surgery should be discussed at length, prior to any procedure being performed. Rectopexy or Delorme’s procedure offer the best success rates to date; however, the choice of surgical procedure must take into account the experience of the surgeon and wishes of the patient.
Unable to display preview. Download preview PDF.
References and Recommended Reading
- 4.Kennedy DK, Hughes ESR, Masterson JP: The natural history of benign ulcer of the rectum. Surg Gyn Obstet 1977, 144:718–720.Google Scholar
- 6.Tjandra JT, Fazio VW, Church JM, et al.: Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum 1992, 35:227–234. One of the largest series of patients with SRUS reported to date (n = 80). The authors report on the clinical features, evaluation, and response to therapy of patients with SRUS and compare them with 11 previous large series. Also, the outcome of treatment is correlated with the type of lesion present and the presence or absence of rectal prolapse.PubMedCrossRefGoogle Scholar
- 9.Keighley MRB, Shouler P: Clinical and manometric features of the solitary rectal ulcer syndrome. Dis Colon Rectum 1984, 27:507–512. This article reports on the manometric findings for patients with SRUS and compares them with normal controls. There is also a good discussion of clinical features and response to various treatment regimens.PubMedCrossRefGoogle Scholar
- 11.vanden Brandt-Grädel V, Huibregtse K, Tytgat GNJ: Treatment of solitary rectal ulcer syndrome with highfiber diet and abstention of straining at defecation. Dig Dis Sci 1984, 29:1005–1008. Although a small study (n = 21), this is the best study to show the benefit of treatment with a high-fiber diet and avoidance of straining with defecation.PubMedCrossRefGoogle Scholar
- 14.Womack NR, Williams NS, Holmfield JHM, Morrison JFB: Pressure and prolapse—the cause of solitary rectal ulceration. Gut 1987, 28:1228–1233. This study assessed the importance of intrarectal pressure and mucosal prolapse as causative factors in SRUS using defecography, manometry, and electromyography. Includes an excellent discussion and review of the pathophysiology of SRUS.PubMedGoogle Scholar
- 16.Vora IM, Sharma J, Joshi AS: Solitary rectal ulcer syndrome and colitis cystica profunda—a clinicopathological review. Indian J Pathol Microbiol 1992, 2:94–102.Google Scholar
- 18.Vaizey CJ, Roy AJ, Kamm MA: Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback. Gut 1997, 41:817–820. A small study (n = 13) documenting the benefit of biofeedback in the treatment of patients with SRUS, despite the absence of any identifiable pretreatment prognostic predictors.PubMedCrossRefGoogle Scholar
- 19.Pescatori M, Quondamcarlo C: A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis 1999, 14:245–249. This article proposes an endoscopic grading system for internal mucosal prolapse, then shows a correlation between the degree of prolapse and severity of symptoms. The authors offer an algorithm for the treatment of SRUS based on the degree of mucosal prolapse seen at proctoscopy.PubMedCrossRefGoogle Scholar
- 27.Goei R, Baeten C, Janevski B, et al.: The solitary rectal ulcer syndrome: diagnosis with defecography. Am J Roentgenol 1987, 149:933–936.Google Scholar
- 41.Sitzler PJ, Kamm MA, Nicholls RJ, McKee RF: Long-term clinical outcome of surgery for solitary rectal ulcer syndrome. Br J Surg 1998, 85:1246–1250. A retrospective review of outcome for patients (n = 81) having surgery for SRUS. This article includes a good review of the surgical options available for the treatment of SRUS.PubMedCrossRefGoogle Scholar
- 42.Schweiger M, Alexander-Williams J: Solitary-ulcer syndrome of the rectum. Its association with occult rectal prolapse. Lancet 1977, 1:70–71.Google Scholar
- 44.Sarles J, Arnaud A, Joly A, Sielezneff I: Internal procidentia of the rectum: therapeutic possibilities. Gastroenterol Clin Biol 1991, 15:124–129.Google Scholar