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. |
