Solitary Rectal Ulcer Syndrome: Diagnosis and lines of Treatment
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This prospective, selection-based study was designed to evaluate the diagnostic profile of various modalities and outcome of different treatment strategies of patients with solitary rectal ulcer syndrome (SRUS) and consisted of full investigations, including proctosigmoidoscopy for patients presenting a picture suggestive of SRUS. Selected patients underwent proctosigmoidoscopy and biopsy; proctography for assessment of anorectal angle (ARA) and the extent of perineal descent (PD); anorectal manometric measurement of resting and maximum squeeze anal pressure (RSP & MSP), functional anal canal length (FACL) and maximum tolerated rectal volume (MTRV). Patients were categorized into two groups: Group A (SRUS associated with rectal prolapse, RP) and Group B (SRUS not associated with RP). Patients were initially treated with conservative measures and followed-up monthly for 3-9 months, biofeedback training for patients with inappropriate contractions of puborectalis muscle. Patients with failed conservative treatment underwent surgical treatment according to the status. There were 12 patients with SRUS; 7 patients with RP (5 females & 2 males) and 5 patients without RP (3 females & 2 males). Straining at defecation, rectal bleeding, tenesmus and constipation were the most common complaints. Solitary ulcers were detected in 7 and multiple ulcers in 5 patients, there were 8 anterior and 4 right antrolateral ulcers. Group A ulcers were significantly wider than group B ulcers. Biopsy examination detected colitis cystica profounda in one patient in group A. There was a significant PD with significant increase in ARA in group A, while other manometric measurements were significantly decreased compared to group B. Seven patients showed partial improvement on conservative treatment and biofeedback training and 2 patients in group B had healed ulcer. Success was manifested as significant reduction of subjective symptoms with a significant improvement of ARA at straining in patients with paradoxical puborectalis. Ulcer excision and direct closure was applied for 3 patients in group B and only one ulcer recurred 2 months after surgery and patient underwent low anterior resection with colo-anal anastomosis. Group A patients underwent posterior abdominal rectopexy; 5 open and 2 laparoscopic. Postoperative proctographic measurements and RSP and MTRV showed a significant improvement compared to preoperative ones, but 2 patients developed recurrent ulcer after open rectopexy, both underwent sigmoid colectomy and reanastomosis. In total, after follow-up period there was significant improvement of patients' symptoms. It could be concluded that SRUS, despite being uncommon entity, patients with persistent anal complaints must be well investigated with proctography and manometric studies that proved to be diagnostic. Prolonged trial with conservative treatment and biofeedback training must be considered prior to surgical treatment. Surgical success depends upon proper patient selection with laparoscopic rectopexy being a superior procedure.