Diagnosis and Management of Solitary Rectal Ulcer Syndrome: Diseases of the Colon & Rectum | August 2026

Introduction:

Solitary rectal ulcer syndrome (SRUS) is a rare, benign rectal disorder characterized by mucosal injury associated with abnormal defecation, mucosal prolapse, rectal intussusception, ischemia, and repetitive mechanical trauma. Despite its name, SRUS does not necessarily present as a single ulcer; lesions can be multiple, erythematous, or polypoid. Patients commonly present with rectal bleeding, mucus discharge, excessive straining, rectal pain, constipation, and incomplete evacuation.

Why was this article needed?

. SRUS is uncommon and its variable clinical and endoscopic appearance can delay diagnosis.

. Polypoid or ulcerative lesions can mimic rectal cancer, inflammatory bowel disease, or ischemic/infectious colitis.

. SRUS frequently coexists with underlying defecatory dysfunction, rectal intussusception, or rectal prolapse.

. Appropriate treatment requires identification of the underlying functional or structural abnormality rather than treatment of the mucosal lesion alone.

Results:

Diagnosis requires integration of clinical history, endoscopic evaluation, and histopathology. Endoscopy can demonstrate shallow ulceration, erythematous mucosa, or polypoid lesions, often involving the anterior rectal wall. Characteristic histological findings include fibromuscular obliteration of the lamina propria, extension of smooth-muscle fibers between crypts, and distortion of glandular architecture. Anorectal manometry and defecography can identify dyssynergic defecation, paradoxical puborectalis contraction, rectal intussusception, and prolapse.

Clinical Impact:

Management should follow a stepwise, mechanism-directed approach. Initial therapy includes patient education, avoidance of excessive straining or digital evacuation, optimization of stool consistency, dietary fiber, and treatment of constipation. Pelvic-floor biofeedback is particularly relevant when dyssynergic defecation is present. Patients with persistent symptoms despite conservative treatment, particularly those with significant internal or full-thickness rectal prolapse, can require surgical correction such as rectopexy.

Bottom Line:

SRUS is best regarded as a manifestation of underlying rectal mucosal prolapse and/or defecatory dysfunction rather than simply an isolated ulcer. Accurate endoscopic and histological diagnosis, followed by assessment of anorectal function and correction of the underlying mechanism, is central to successful management.