Solitary Rectal Ulcer Syndrome

What is solitary rectal ulcer syndrome?

Solitary rectal ulcer syndrome (SRUS) is a chronic (long-term), noncancerous condition where sores form inside your rectum. Your rectum connects your colon (large intestine) to your anus (butthole). Stool passes through your rectum and your anus when you have a bowel movement (poop).

But the name “solitary rectal ulcer syndrome” is misleading. For example, if you have SRUS, you may have a single (“solitary”) ulcer, or you may have more than one. Also, the sores aren’t always ulcers or even only in your rectum. They may be inflamed tissue or located in the part of your colon above your rectum.

There’s still a lot that researchers are learning about SRUS, including causes and the most effective treatments.

How common is solitary rectal ulcer syndrome?

Solitary rectal ulcer syndrome is rare. It occurs in about 1 out of every 100,000 people. Most people who get this diagnosis are in their 30s or 40s, but it also affects children and older adults.

Are rectal ulcers serious?

Although the ulcers can be uncomfortable, they’re usually not serious. The condition that’s causing a rectal ulcer can be serious, though. This is why you should see your provider to receive a diagnosis if you’re experiencing symptoms of solitary rectal ulcer syndrome.

What are the symptoms of rectal ulcer syndrome?

Symptoms of a rectal ulcer usually develop gradually and involve unpleasant bathroom visits. Signs and symptoms of a rectal ulcer include:

• Rectal bleeding (blood is usually bright red).
• Mucus or blood in your stool.
• Straining to poop or having too few bowel movements.
• Feeling the frequent urge to poop but being unable to empty your bowels.
• Anal discomfort, especially when pooping.
• A feeling of fullness in your pelvis.

Up to 25% of people with solitary rectal ulcer syndrome don’t have symptoms.

What causes solitary rectal ulcer syndrome?

Experts haven’t identified a single cause. But several conditions that can injure the lining of your rectum may cause rectal ulcers to form. For example, solitary rectal ulcer syndrome often happens alongside:

• Rectal prolapse: A condition that causes your rectum to stretch and stick out of your anal opening.
• Rectal intussusception: A condition that causes part of your rectum to slip inside (telescope) a nearby part of your rectum.
• Severe or chronic (long-term) constipation: A condition that makes it difficult to pass stools. Using fingers to remove stool that’s stuck can also damage tissue lining your rectum and potentially lead to rectal ulcers.
• Fecal (bowel) incontinence: A condition that makes it difficult to control when you poop or how much stool you pass.

One theory is that solitary rectal ulcer syndrome happens when the muscles that help you poop (pelvic floor muscles) don’t coordinate correctly to allow stools to pass. The lack of coordination can lead to ulcers. This is especially the case if you have a condition like rectal prolapse or intussusception that causes tissues that don’t normally come into contact to touch or rub together.

How are rectal ulcers diagnosed?

Your healthcare provider will ask about your symptoms and bathroom habits that may have caused your symptoms (like frequently straining to poop). To check for rectal ulcers, providers use digital rectal exams and imaging tests.

The most common test is an:

• Endoscopy: Your provider may insert a scope inside you to check for ulcers. Most scopes have cameras on the end that allow your provider to see inside your lower digestive tract. An anoscopy examines your anus. A flexible sigmoidoscopy examines your rectum and the lower part of your colon. A colonoscopy examines your entire colon.

You may need additional tests so your provider can rule out conditions that cause symptoms similar to solitary rectal ulcer syndrome, like inflammatory bowel disease (IBD) and colon cancer. Tests include:

• Transrectal ultrasound: During a transrectal ultrasound, a provider inserts a small probe into your rectum. The probe uses sound waves to show images of the inside of your rectum so your provider can see ulcers and other growths.
• Defecography: This test can show if a condition like rectal prolapse or intussusception is likely causing your ulcer. During a defecography test, X-rays or an MRI (magnetic resonance imaging) machine will record how your muscles work in real-time to help you poop.
• Anorectal manometry: Anorectal manometry shows how your pelvic floor muscles are coordinating to help you poop. During the test, a provider inserts a flexible tube with sensors (transducer) inside your rectum. It records how your muscles respond to pressure.
• Biopsy: During the endoscopy, your provider may take a biopsy (sample) of the tissue surrounding the ulcer and send it to a lab. Lab tests can show if the cells are benign (as with SRUS) or cancerous.

What are the treatments for rectal ulcers?

Treatment for solitary rectal ulcer syndrome depends on the severity of your symptoms and what’s causing them.

Many people with mild to moderate symptoms find relief by changing their eating habits and bowel habits to relieve constipation. Often, not straining to poop gives your ulcer time to heal. Your provider may recommend that you:

• Drink plenty of water. Dehydration can make stools hard, dry and more difficult to pass. Your provider can guide you on how much water you should be drinking daily to prevent dehydration. They may also tell you to avoid drinks that can dehydrate you, like caffeinated drinks and alcoholic beverages.
• Eat a fiber-rich diet. Fiber-rich foods can relieve constipation. Fiber softens stool and helps it pass through your intestines faster.
• Avoid straining during bowel movements. Straining or pushing too hard when pooping can damage your rectum and cause ulcers. It’s best to wait for nature to take its course rather than strain come toilet time.
• Try a laxative. Your provider may recommend taking a stool softener or bulking laxative to make stools easier to pass. Ask your provider about which laxative you should take and how long you should take it.
• Try medications that treat ulcers: A corticosteroid cream or suppository (such as hydrocortisone) can reduce inflammation, relieve pain and help the ulcers heal. Sucralfate (Carafate®) and sulfasalazine (Azulfidine®) are prescription medicines you can take by mouth to treat ulcers.

If these treatments aren’t providing relief, your provider may recommend biofeedback therapy. This type of behavior modification therapy can help you recognize when you’re tightening the muscles you use to poop so that you relax them instead. Biofeedback can teach you not to strain when pooping.

When does a rectal ulcer require surgery?

If rectal prolapse or intussusception is causing your rectal ulcers, you may need a surgical procedure called a rectopexy to repair your rectum and place it into position. Your provider can perform this procedure laparoscopically or robotically (through small incisions).

How can you prevent solitary rectal ulcer syndrome?

It isn’t always possible to prevent rectal ulcers. You can reduce your risk, though, by trying to keep your bowel movements regular so you’re not straining at the toilet and damaging rectal tissue. Staying hydrated, eating high-fiber foods and trying stool softeners can help.

What is the outlook for people with solitary rectal ulcer syndrome?

Rectal ulcers are benign and don’t cause serious long-term medical problems. Still, they can cause pain and ongoing unpleasant symptoms without proper treatment.

Your provider will work with you to determine what caused the tissue damage inside your rectum. They can prescribe treatments and recommend lifestyle changes that can help manage solitary rectal ulcer syndrome.

When should I see my healthcare provider?

Contact your healthcare provider if you’re bleeding from your anus, finding blood in your stool or experiencing persistent pain during bowel movements. They’ll work with you to determine if you have a rectal ulcer.

What questions should I ask my healthcare provider?

Questions you may ask include:

• What’s causing me to have rectal ulcers?
• What treatments would you recommend to get rid of my ulcer?
• Will I need treatments to address an underlying condition that’s causing rectal ulcers?
• How long should it take for my ulcer to disappear once I begin treatment?
• How can I care for my skin to help my ulcer heal?