Solitary Rectal Ulcer

One of my friends, Eby, came out of the Proctoscopy Room saying something about a filthy rectal ulcer, apparently what he thought was a Solitary Rectal Ulcer. Another fellow, Chandra, asked him whether it was anterior or posterior. He replied something but I was already wondering what could be the significance of that question.

It turns out that Solitary Rectal Ulcer Syndrome (SRUS) is something unique and you can't just go about labeling a single ulcer as SRU.

It is always located on the anterior aspect of the rectum 4 to 12 cm from the anal verge and is thought to correspond to the location of the puborectalis “sling.” It is frequently, although not exclusively, associated with internal intussusception or full-thickness rectal prolapse. Patients are typically young and female, however, with an average age of 25 years and a history of straining and difficult evacuation.

Sabiston, 18th Edition

A quick review of lengths: 

Anal canal: 2.5-4cm 

Rectum: 12cm

The cause of this SRUS, according to Sabiston is an intussuseption lead point which occurs due to repeated straining and ulceration at this point. 

Some fellows might indulge in digital self-disimpaction (Seriously. Yuck)

You have to differentiate this from malignancy, infection or Chrons. The anterior nature of this ulcer helps to clinch the diagnosis. Defecography is the investigation of choice. 

Treat the cause for intususseption, which inevitably means treat the prolapse through an abdominal procedure.  Ripstein is supposed to be considered but no clear indications for this.