Solitary Rectal Ulcer Syndrome (SRUS)

What is Solitary Rectal Ulcer Syndrome?

Solitary Rectal Ulcer Syndrome (SRUS) is a rare, non-cancerous condition related to chronic straining and difficulty during bowel movements. Despite its name, it can involve single or multiple ulcers, or sometimes just reddened, inflamed areas in the rectum without a true ulcer. It occurs when the muscles of the pelvic floor and anus do not relax properly during defecation, leading to trauma to the rectal lining. This trauma is often caused by a combination of high pressure from straining and, in many cases, direct trauma from patients digitally manipulating the rectum to aid evacuation. The condition is a manifestation of a functional disorder known as obstructed defecation.

Common Symptoms

The symptoms of SRUS can be varied and often overlap with other anorectal conditions. The most common symptoms include:

• Rectal bleeding: This is the most frequent symptom, occurring in over 80% of patients.
• Straining: A significant feeling of effort is needed to pass stool.
• Feeling of incomplete evacuation: The sensation that the rectum is not empty after a bowel movement.
• Pelvic or anal pain: A dull, aching pain is common.
• Mucus discharge from the rectum.
• Need for digital evacuation: Many patients report needing to use a finger to help pass stool.
• Constipation or diarrhea.

What causes SRUS?

SRUS is caused by a combination of factors that lead to chronic injury of the rectal lining. The underlying issue is a problem with the mechanics of defecation.

• Pelvic Floor Dyssynergia: This is a key cause, where the pelvic floor muscles, including the puborectalis and anal sphincter, paradoxically contract instead of relaxing during a bowel movement. This creates an obstruction that patients must strain against.
• Internal Rectal Prolapse (Intussusception): The constant straining can cause the rectal wall to fold in on itself (intussusception). This prolapsing tissue can become congested, ischemic, and traumatized at its leading point, leading to ulcer formation.
• Direct Trauma: Many patients with obstructed defecation resort to digitally manipulating the anus and rectum to assist with evacuation. This repeated direct trauma can cause or worsen the ulceration.
• Prolonged Straining: Chronic straining increases the pressure inside the rectum, which can reduce blood flow to the mucosal lining and make it more susceptible to injury.

How is SRUS diagnosed?

The diagnosis of SRUS is made through a combination of a patient's history, physical examination, and specialized tests.

• Endoscopy (Flexible Sigmoidoscopy or Colonoscopy): This is the most important test for diagnosis. A doctor will look inside the rectum with a camera to identify the characteristic ulcer or inflamed area. The ulcer is typically located on the anterior (front) wall of the mid-to-lower rectum. Biopsies are taken to confirm the diagnosis and rule out other conditions. The microscopic appearance of the biopsy, showing fibromuscular obliteration of the lamina propria (replacement of the normal tissue with muscle and scar-like fibers), is the hallmark of SRUS.
• Defecography: This is a specialized imaging study (either X-ray or MRI) that shows the anatomy and function of the rectum and pelvic floor during a simulated bowel movement. It is very helpful for identifying internal rectal prolapse and pelvic floor dyssynergia, which are the underlying causes of SRUS.
• Anorectal Manometry: This test measures the pressures of the anal sphincter muscles and can show the paradoxical contraction of the muscles during attempted defecation, confirming a diagnosis of dyssynergic defecation.

How is SRUS treated?

Treatment for SRUS is focused on correcting the underlying defecation disorder. The primary goal is to normalize bowel habits and eliminate straining.

• Bowel Retraining and Biofeedback: This is the cornerstone of treatment. Patients work with a specialized physical therapist to learn how to properly relax their pelvic floor muscles during defecation. Biofeedback uses sensors to give patients real-time information about their muscle activity, helping them to regain conscious control over this function. This is the most effective treatment for the underlying dyssynergic defecation and can lead to healing of the ulcer.
• Dietary Changes and Laxatives: A high-fiber diet, adequate fluid intake, and the use of stool softeners or osmotic laxatives are important to ensure that the stool is soft and easy to pass, which reduces the need for straining.
• Topical Medications: While not curative, topical agents like sucralfate enemas can sometimes help to coat the ulcer and promote healing.
• Surgery: Surgery is reserved for a small number of patients with severe symptoms who have failed conservative treatments. Surgical options are aimed at correcting the internal rectal prolapse. Procedures like a ventral mesh rectopexy (a minimally invasive procedure to lift and support the rectum) can be effective. In very rare and severe cases, a permanent stoma (colostomy or ileostomy) may be necessary to relieve symptoms.

Self-Care for SRUS

Managing SRUS involves a commitment to changing bowel habits and behaviors to reduce rectal trauma.

• High-Fiber Diet: Incorporate plenty of fruits, vegetables, and whole grains into your diet. A fiber supplement, such as psyllium, can be very effective.
• Stay Hydrated: Drink plenty of water throughout the day to help soften your stool.
• Timed Toileting: Try to have a bowel movement at the same time each day, such as after a meal, to take advantage of the natural contractions of the colon.
• Avoid Straining: Do not force a bowel movement. If it is not happening, get up and try again later. Proper positioning on the toilet, with feet elevated on a stool (like a Squatty Potty), can help to straighten the anorectal angle and make evacuation easier.
• Stop Digital Evacuation: It is crucial to stop the habit of using fingers to assist with defecation, as this continues to traumatize the rectal lining.

Is Solitary Rectal Ulcer Syndrome a form of cancer?
No, SRUS is a completely benign (non-cancerous) condition. However, because it can cause bleeding and an ulcer, it is very important to have it properly diagnosed with an endoscopy and biopsy to rule out rectal cancer, which can have similar symptoms.

Can SRUS be cured?
Yes, the ulcer itself can heal completely. The key to cure is successfully treating the underlying cause, which is the obstructed defecation disorder. For most people, this is achieved through biofeedback physical therapy and changes in bowel habits. For the small number of people who require surgery to correct an internal prolapse, the success rates are generally high.

Why is it called 'solitary' if there can be more than one ulcer?
The name is historical and can be misleading. When the condition was first described, it was typically seen as a single ulcer. We now know that the presentation can range from a single ulcer to multiple ulcers, or even just a patch of red, inflamed tissue (proctitis) without a distinct ulcer. The underlying cause and treatment are the same regardless of the appearance.

• Tjandra JJ, Fazio VW, Church JM, Lavery IC, Oakley JR, Milsom JW. Solitary rectal ulcer syndrome: a study of 61 patients. In: The ASCRS Textbook of Colon and Rectal Surgery. 4th ed. Springer; 2022.
• Cleveland Clinic. Solitary Rectal Ulcer Syndrome. Accessed September 28, 2026. https://my.clevelandclinic.org/health/diseases/21189-rectal-ulcers
• Mayo Clinic. Solitary rectal ulcer syndrome. Published August 12, 2021. Accessed October 12, 2025. https://www.mayoclinic.org/diseases-conditions/solitary-rectal-ulcer-syndrome/symptoms-causes/syc-20352871