Other nonneoplastic

Solitary rectal ulcer syndrome

Deputy Editor-in-Chief: Catherine E. Hagen, M.D.
Raul S. Gonzalez, M.D.

Last author update: 28 October 2021
Last staff update: 19 May 2023

Copyright: 2003-2023,, Inc.

PubMed search: solitary rectal ulcer syndrome

Raul S. Gonzalez, M.D.
Page views in 2022: 33,302
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Cite this page: Gonzalez RS. Solitary rectal ulcer syndrome. website. Accessed June 4th, 2023.
Definition / general
  • Solitary or multiple ulcerated or polypoid lesions 4 - 10 cm from anal margin
Essential features
  • Not always solitary, not always rectal, not always ulcerated, not really a syndrome
  • Mucosal prolapse type change resulting in rectal lesions
  • Also called mucosal prolapse syndrome (may be a better term since not necessarily solitary, ulcerated or rectal)
  • Uncommon (incidence of 1 per 100,000 per year)
  • Usually third and fourth decade
  • More common in women
  • Rarely in children (Pediatrics 2002;110:e79)
  • Usually in rectosigmoid colon
  • Abnormal function of anal and pelvic floor musculature during defecation, causing rectal mucosal prolapse or intussusception
Clinical features
Case reports
  • 45 year old man complaining of constipation and rectal bleeding is found to have an ulcerated rectal lesion on colonoscopy (Case of the Month #527)
  • High fiber diet, laxatives, topical steroids
  • Possibly resection
Gross description
  • Well demarcated irregular ulcer(s) on rectal wall
  • Also polypoid, rough, erythematous lesions
  • Mucosal thickening
Microscopic (histologic) description
  • Superficial mucosal ulceration and villiform change
  • Crypt hyperplasia and elongation with focal dilation (some glands diamond shaped)
  • Fibromuscular hyperplasia of lamina propria
  • Thickened muscularis mucosae with splayed fibers
  • Ectatic capillaries
  • Minimal inflammation
  • May have inflammatory pseudomembranes
  • Late changes resemble colitis cystica profunda
Microscopic (histologic) images

Contributed by Andrey Bychkov, M.D., Ph.D., Jian-Hua Qiao, M.D. and Raul S. Gonzalez, M.D. (Case #527)

Polypoid shape

Solitary rectal ulcer

Crypt hyperplasia

Disarrayed muscularis mucosa

Haphazardly arranged benign colonic crypts

Distorted diamond shaped glands

Ulcerated, reactive mucosa Ulcerated, reactive mucosa

Ulcerated, reactive mucosa

Smooth muscle wisps

Smooth muscle wisps

Granulation tissue

Granulation tissue

Sample pathology report
  • Rectum, ulcer, biopsy:
    • Colonic mucosa with prolapse type change, mild acute inflammation and focal erosion (see comment)
    • Comment: The findings are compatible with so called solitary rectal ulcer syndrome.
Differential diagnosis
Board review style question #1

Solitary rectal ulcer syndrome most frequently occurs in what patient population?

  1. Elderly men
  2. Female infants
  3. Middle aged women
  4. Young adult men
Board review style answer #1
C. Middle aged women

Comment Here

Reference: Solitary rectal ulcer syndrome
Board review style question #2
Which of the following is true about solitary rectal ulcer syndrome?

  1. Patients demonstrate typical associated systemic symptoms
  2. Prolapse of intestinal mucosa is specific to this disease entity
  3. Roughly 30% of patients have multiple lesions
  4. The diagnosis cannot be made without microscopic ulceration
Board review style answer #2
C. Roughly 30% of patients have multiple lesions. Despite the name, "solitary rectal ulcer syndrome" is not always a solitary finding. Approximately 30% of patients will demonstrate multiple rectal ulcers on colonoscopy. Answer A is incorrect because solitary rectal ulcer syndrome is not a systemic syndrome, meaning patients will not have associated systemic symptoms. Answer B is incorrect because prolapse of intestinal mucosa can be seen histologically in other diseases, such as diverticulosis. Answer D is incorrect because microscopic ulceration is often but not always encountered, meaning it is not required to establish the diagnosis.

Comment Here

Reference: Solitary rectal ulcer syndrome
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