The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.
[3] The most common signs and symptoms are bleeding, which can vary from minor to severe, rectal prolapse and incomplete evacuation (35%-76% of cases).
[3] Long term injury to the rectal mucosa and ischemic trauma are thought to be the main mechanisms.
This pelvic floor muscle is normally supposed to relax, thereby straightening the anorectal angle and allowing rectal contents to be evacuated.
[8] Inappropriate contraction of puborectalis in the squatting position causes traumatic compression of the rectal wall against the anal canal.
[5] These conditions create chronic vascular trauma (ischemia or hypoperfusion) in the rectal mucosa,[1] which predisposes it to ulceration,[8] and pressure necrosis.
[4] Even the initial small areas of an intussusception can lead to vascular injury and reduce blood supply to the region.
[5] The nature of the tissue changes can vary from simple erythema (redness) / hyperaemia (increased blood flow) of the mucosa in 18% of cases,[1] to a chronic-appearing, small, shallow ulcer with nodular margins and a white or sloughing base.
[5] Defecography findings in SRUS may include: Endoanal ultrasound can determine the depth of the ulcer and the structure of the external and internal anal sphincters.
[8] Endoanal ultrasound findings in SRUS include: As a diagnostic investigation, anorectal manometry can evaluate defecation function.
It can highlight excessive and prolonged straining effort during defecation attempts, and also record any improvement in function before and after treatment interventions.
[1] The exact treatment depends on the severity of the symptoms, the severity/type of SRUS, and whether rectal prolapse is present or absent.
[1] Where conservative measures fail, or with severe disease and symptoms, or with significant anatomical defects, surgical options may be indicated.
Where indicated, conservative management may also involve treatment of psychological problems,[5] and avoidance of anoreceptive sex (to prevent trauma to the rectum).
[8] Biofeedback targets pelvic floor behaviors and enables a reprogramming of autonomic neurologic pathways associated with defecation.
Research studies have shown that there is improved blood flow to the rectal mucosa after biofeedback therapy.
[1] A randomized controlled study compared topical agents (dexamethasone, sucralfate and bismuth) with biofeedback.
[8] They are thought to work by reducing inflammation and physically forming a barrier over the surface of the ulcer to protect it from irritants, thereby allowing it to heal.
[6] It has been suggested that any treatment which only addresses the ulcer without correcting the underlying causes will typically lead to recurrence.
According to one report, such measures have generally unfavorable results, and sometimes the ulcer returns deeper and larger than before the treatment.
[8] Excision (removal) of the ulcer and suturing the resulting defect with surrounding healthy mucosa has been reported.
[8] Ulcers in the upper part of the rectum may be accessible to local excision using a transanal minimally invasive approach (TAMIS).
[8] Some authors state rectopexy is suitable in highly select cases,[9] while others say it is the procedure of choice,[7] since it directly addresses the most likely cause.
[13] In comparison with ventral mesh rectopexy, STARR may result in higher rates of bowel urgency, recurrence and other complications, some of which may be serious.
[13] The following "last resort" surgical procedures (which may have significant consequences) have been reported in severe, persistent or recurrent cases of SRUS: The condition is relatively rare, but the exact prevalence is not known.
[1] Misdiagnosis as inflammatory bowel disease (IBD) or rectal polyps may hide the true prevalence of SRUS.