Field Of Vision
Copyright ©2012 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Dec 7, 2012; 18(45): 6541-6545
Published online Dec 7, 2012. doi: 10.3748/wjg.v18.i45.6541
Solitary rectal ulcer syndrome in children: A literature review
Seyed Mohsen Dehghani, Abdorrasoul Malekpour, Mahmood Haghighat
Seyed Mohsen Dehghani, Gastroenterohepatology Research Center, Shiraz Transplant Research Center, Nemazee Teaching Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz 71937-11351, Iran
Abdorrasoul Malekpour, Mahmood Haghighat, Gastroenterohepatology Research Center, Nemazee Teaching Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz 71937-11351, Iran
Author contributions: Dehghani SM, Malekpour A and Haghi-ghat M searched for articles, wrote the paper and approved the final draft.
Correspondence to: Seyed Mohsen Dehghani, MD, Associate Professor of Pediatric Gastroenterology, Gastroenterohepatology Research Center, Shiraz Transplant Research Center, Nemazee Teaching Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz 71937-11351, Iran.
Telephone: +98-711-6261775 Fax: +98-711-6474298
Received: August 2, 2012
Revised: September 20, 2012
Accepted: September 29, 2012
Published online: December 7, 2012


Solitary rectal ulcer syndrome (SRUS) is a benign and chronic disorder well known in young adults and less in children. It is often related to prolonged excessive straining or abnormal defecation and clinically presents as rectal bleeding, copious mucus discharge, feeling of incomplete defecation, and rarely rectal prolapse. SRUS is diagnosed based on clinical symptoms and endoscopic and histological findings. The current treatments are suboptimal, and despite correct diagnosis, outcomes can be unsatisfactory. Some treatment protocols for SRUS include conservative management such as family reassurance, regulation of toilet habits, avoidance of straining, encouragement of a high-fiber diet, topical treatments with salicylate, sulfasalazine, steroids and sucralfate, and surgery. In children, SRUS is relatively uncommon but troublesome and easily misdiagnosed with other common diseases, however, it is being reported more than in the past. This condition in children is benign; however, morbidity is an important problem as reflected by persistence of symptoms, especially rectal bleeding. In this review, we discuss current diagnosis and treatment for SRUS.

Key Words: Solitary rectal ulcer syndrome, Rectal bleeding, Children, Diagnosis, Treatment

Citation: Dehghani SM, Malekpour A, Haghighat M. Solitary rectal ulcer syndrome in children: A literature review. World J Gastroenterol 2012; 18(45): 6541-6545

Solitary rectal ulcer syndrome (SRUS) is an uncommon chronic and benign rectal disorder often related to abnormal defecation or straining. It was first described by Cruveilhier[1] in 1829, when he reported four unusual cases of rectal ulcers. The term “solitary ulcers of the rectum” was used by Lloyd-Davis in the late 1930s and in 1969 the disease became widely recognized after a review of 68 cases by Madigan et al[2] and few years later, a more detail pathogenic concept of the disease was reported by Rutter et al[3]. SRUS is an infrequent or unrecognized or misdiagnosed disorder, with an estimated prevalence of 1 in 100 000 persons per year[4]. Solitary rectal ulcer is a misnomer as ulcers are found in 40% of patients, while 20% of patients have a solitary ulcer, and the rest of the lesions are different in shape and size, including hyperemic mucosa to broad-based polypoid lesions[5]. The disease process also may involve the sigmoid colon[6].

Although it is uncommon, it is well recognized in adult populations[3]. SRUS seems to be rare in childhood[7-10] and may masquerade as other more common conditions, causing difficult-to-manage lower gastrointestinal symptoms. Opinion differs regarding the best treatment for this troublesome condition, varying from conservative management and enema preparations to more invasive surgical procedures such as rectopexy[11].

In this review article, several aspects of this syndrome will be evaluated with an especial focus on the condition in children. Detailed risk factors, causes, and treatment methods will help guide future treatment and prevention strategies in children.

Pathophysiology and clinical presentation

The pathophysiology of SRUS is incompletely understood; however, rectal hypersensitivity leading to the persistent desire to defecate and sensation of incomplete evacuation may have a role in SRUS[12]. Inappropriate contraction of the puborectalis muscle and rectal mucosal prolapse have been commonly implicated, although trauma and ischemia have been suspected in some children[7,13]. In children, secondary to chronic mechanical and ischemic trauma, inflammation by hard stools, and intussusception of the rectal mucosa, some histological features of SRUS can be seen such as fibromuscular obliteration of the lamina propria and disorientation of muscle fibers[14].

In our previous study of 256 children who were evaluated endoscopically for recurrent lower gastrointestinal bleeding, 4.7% had this syndrome[15]. In adult patients, men and women are affected equally, with a small predominance for women[16], but 75%-80% of children with SRUS are boys[15,17]. Suresh et al[18] have evaluated 325 children aged < 18 years during 8 years for various indications such as bleeding, polyps and anal fissure. Twenty-two (6.8%) children were diagnosed with SRUS and ranged in age from 18 months to 18 years (median: 10 years), and 18 (81.8%) of these were ≥ 8 years of age. The male to female ratio in this group was 1.4:1. To date, the youngest patient with SRUS was a child of 1.5 years[18]; Gabra et al[19] also have reported two boys with SRUS who were 2 and 3 years old.

The average time from the onset of symptoms to diagnosis is 5 years, ranging from 3 mo to 30 years in adults, which is longer than in pediatric patients (3.2 years, range: 1.2-5.5 years)[15,17,20-22]. This syndrome results from obstructed defecation secondary to internal rectal prolapse with a collection of symptoms including rectal bleeding, passage of mucus and straining on defecation, perineal and abdominal pain, tenesmus, feelings of incomplete defecation, constipation, and rectal prolapse[23-25]. The amount of blood varies from a little fresh blood to severe hemorrhage that requires blood transfusion[26-28]. Up to 26% of patients can be asymptomatic and may not show the bleeding that is discovered incidentally while investigating other diseases[5]. The use of digital manipulation to assist with a bowel movement is variably reported in patients with SRUS[15,29]. Bright-red blood from the rectum or mucoid rectal discharge, tenesmus, proctalgia, and constipation are the major symptoms. Some children present with apparent diarrhea (because of prolonged visits to the bathroom) and the associated bleeding, abdominal pain, and tenesmus may suggest to clinicians the presence of inflammatory bowel disease[25].


SRUS is a relatively uncommon but bothersome and easily misdiagnosed condition of childhood. Clinical suspicion and paraclinical evaluations are needed and diagnosis is via symptomatology in combination with endoscopic and histological findings[17]. A complete and thorough history is most important in the initial diagnosis of SRUS. It is essential to differentiate SRUS from other devastating, chronic, and potentially lethal disorders such as inflammatory bowel disease, amebiasis, lymphogranuloma venereum, chronic ischemic colitis, endometriosis, colitis cystica profunda, and malignancy. Obstructive symptoms (anismus) in children may be interpreted by parents as constipation. Concomitant haematochezia may be misinterpreted as originating from an anal fissure caused by constipation, or as other causes of rectal bleeding such as a juvenile polyp[30-32].

Defecography is a useful method for determining the presence of intussusception or internal or external mucosal prolapse and can demonstrate a hidden prolapse, as well as a non-relaxing puborectalis muscle and incomplete or delayed rectal emptying[33]. Barium enema shows granularity of the mucosa, polypoid lesion, rectal stricture and ulceration, and thickened rectal folds; all of which are nonspecific findings[33,34]. Temiz et al[35] have recommended that defecography and anorectal manometry should be performed in all children with SRUS to define the primary pathophysiological abnormality and to select the most appropriate treatment protocol.

The endoscopic spectrum of SRUS varies from simple hyperemic mucosa to small or giant ulcers to broad-based polypoid lesions of different sizes. Macroscopically, SRUS typically appears as shallow ulcerating lesions on a hyperemic surrounding mucosa, most often located on the anterior wall of the rectum at 5-10 cm from the anal verge. Ulcers may range from 0.5 to 4 cm in diameter but usually are 1-1.5 cm in diameter[5,15,30].

Histological examination of biopsy material is necessary to confirm a diagnosis of SRUS. The histological criteria for diagnosis are as follows: fibrous obliteration of the lamina propria, streaming of fibroblasts and muscle fibers between crypts, thickening of muscularis mucosa, branching and distorted glandular crypts and diffuse collagen infiltration of the lamina propria[15,36-38].

Recent studies have shown the usefulness of anorectal ultrasound in assessing internal anal sphincter thickness, which is shown to be increased in patients with this syndrome[37,39], and it has been suggested that sonographic evidence of a thick internal anal sphincter is highly predictive of high-grade rectal prolapse and intussusception in patients with SRUS[39].

There is a need for a high index of suspicion for the possibility of SRUS in young children with clinical picture of nonspecific proctitis.


The most frustrating aspect of SRUS is the difficulty in treatment; experiences have shown that most therapeutic regimens are inadequate. There are few data on treatment and its outcome in children with SRUS. In most reported pediatric case series, active intervention using enemas[15], laxatives[40], and surgical approaches have been used more frequently than behavioral modification, mainly biofeedback therapy in adults[11,41-45].

Some suggestions for the treatment of SRUS include reassurance of the patient and parents that the lesion is benign, encouragement of a high-fiber diet[46], avoidance of straining, regulation of toilet habits, and attempt to discuss any psychosocial factors[20,36,37,47,48]. The use of a high-fiber diet, in combination with stool softeners and bulking laxatives, and avoidance of straining have had varying responses[4,46].

In children, primary medical treatment is proposed for most cases[49]. Topical application of sucralfate can be effective for treatment of SRUS in some patients[15,50]. Many medications that are useful in the treatment of patients with inflammatory bowel disease have been tried in those with SRUS, such as sulfasalazine and corticosteroids, with varying responses[16,51]. In one study, oral salicylate and other topical agents such as mesalamine and steroids were not effective[52]. Endoscopic application of human fibrin sealant[53], laser therapy[54], and biofeedback[45,47,48] are some of the effective treatment methods for SRUS.

A therapeutic role for botulinum toxin injection into the external anal sphincter for the treatment of SRUS and constipation associated with dyssynergia of defecation dynamics has been reported by Keshtgar et al[55]. The effect of botulinum toxin lasts approximately 3 mo, which may be more beneficial than biofeedback therapy[55].

Surgical methods for treatment of SRUS are rectopexy[42,43,56], excision[4,5,16] and Delorme’s procedure[41,44,57,58].

The choice of treatment protocol depends on acuteness of symptoms and whether there is an underlying rectal prolapse or not[25,31]. Maintaining compliance in children may prevent progression to the type of long-term morbidity and treatment resistance sometimes seen in adults with this condition[25]. Recommended treatment in children by Abbas et al[59] is initially conservative, but, if that fails, transrectal resection followed by a high-fiber diet. Conservative management including behavioral modification and reduction of time spent straining at defecation has been reported as a good method[25,46,60].

Compliance with simple behavioral modification appears to produce a good outcome in childhood SRUS, probably because of the short disease duration compared with adults.

Early recognition and management of these patients may avoid some of the chronic long-term morbidity often associated with this condition; however, late relapse because of noncompliance is a substantial risk and children should be followed up long term.

SRUS is thought to be part of the bigger disease process known as mucosal prolapse syndrome, which incorporates inflammatory cloacogenic polyps, inflammatory cap polyps, and gastric antral vascular ectasia. In fact, all these syndromes have the same histological features[61]. As a result of the wide endoscopic spectrum of SRUS and the fact that the condition may go unrecognized or, more commonly, misdiagnosed, it is crucial to take biopsy specimens from the involved area to make a positive confirmation of the diagnosis and to exclude other diagnoses including malignancy[31,62].

The exact etiology is unknown[30,63,64] but it has also been noted that this syndrome is often associated with trauma resulting in focal ischemia and ulceration, pelvic floor disorders[64], mucosal prolapse[14,52,64,65] and/or a larger systemic process[66]. Also, it has been associated with perineal descent, nonrelaxing puborectalis syndrome, and rectal prolapse[21,52]. In children, paradoxical contraction of pelvic floor and external anal sphincter muscles contributes to constipation, rectal prolapse, ischemia and finally rectal ulcer.

Diversity of the clinical presentation of SRUS requires a high index of suspicion of both the clinician and the pathologist for the definite diagnosis[30].

The clinicopathological similarities between SRUS and inflammatory bowel disease and the limited pediatric experience of these conditions may lead to difficulties in differentiating these conditions, and could result in under-reporting of SRUS in this age group.

It can present as more common childhood intestinal conditions such as inflammatory bowel disease or constipation, causing difficult-to-manage lower gastrointestinal symptoms. Also, it may present as polypoid mass lesions[67]. A biopsy is required for confirmation of diagnosis, because ulceration may not be apparent at the time of endoscopy. SRUS should be considered in children presenting with rectal bleeding, mucorrhea and excessive straining during defecation.

Biofeedback[44,45,47,48], sucralfate enema[15,50] and surgery seem to be ideal strategies because they aim to correct the underlying processes[57,58]. Behavioral modification or biofeedback therapy improves both rectal blood flow and symptoms and includes bowel habit training, avoiding excessive straining, and normalization of pelvic floor coordination[46-48,68,69]. Surgery is indicated in children with persistent bleeding per rectum not amenable to medical therapy and includes rectopexy, excision of ulcer, and rarely colostomy[42-44,56]. In children, a multitude of procedures have been advocated for rectopexy and a cure rate of at least 90% has been reported for posterosagittal rectopexy[43]. Also, El-Hemaly et al[70] have reported that the results of surgery and biofeedback are satisfactory in comparison to conservative treatment.

Most patients with SRUS in childhood have a satisfactory outcome using a simple behavioral modification approach. Ongoing follow-up to reinforce behavioral modification is important and may avoid long-term, treatment-resistant disease into adulthood. Despite the previous reports about SRUS in children that indicate low prevalence of the disease in childhood, recently we have been faced with higher prevalence rates in this age group. It seems that detailed and effective diagnosis methods such as endoscopy and histological examinations, as well as more attention by clinicians to this syndrome in children, have improved the diagnosis rate of the disease. Despite this being a benign condition in children, morbidity remains a problem as reflected by persistence of symptoms especially bleeding per rectum. Therefore, we are faced with an important condition that needs more attention and attempts for prevention and treatment.

More studies are needed to evaluate all of the aspects of the syndrome in children and to recommend the best treatment protocol. Every child with SRUS must be assessed individually using all modalities of investigation to define clearly the underlying pathophysiology, and to select the appropriate treatment strategies.


Peer reviewer: Andrzej S Tarnawski, MD, PhD, DSc, Professor of Medicine, Chief Gastroenterology, VA Long Beach Health Care System, University of California, Irvine, CA, 5901 E. Seventh Str., Long Beach, CA 90822, United States

S- Editor Gou SX L- Editor Kerr C E- Editor Li JY

1.  Cruveilhier J. Ulcere chronique du rectum. Anatomie pathologique du corps humain. 1829;.  [PubMed]  [DOI]
2.  Madigan MR, Morson BC. Solitary ulcer of the rectum. Gut. 1969;10:871-881.  [PubMed]  [DOI]
3.  Rutter KR, Riddell RH. The solitary ulcer syndrome of the rectum. Clin Gastroenterol. 1975;4:505-530.  [PubMed]  [DOI]
4.  Martin CJ, Parks TG, Biggart JD. Solitary rectal ulcer syndrome in Northern Ireland. 1971-1980. Br J Surg. 1981;68:744-747.  [PubMed]  [DOI]
5.  Tjandra JJ, Fazio VW, Church JM, Lavery IC, Oakley JR, Milsom JW. Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum. 1992;35:227-234.  [PubMed]  [DOI]
6.  Burke AP, Sobin LH. Eroded polypoid hyperplasia of the rectosigmoid. Am J Gastroenterol. 1990;85:975-980.  [PubMed]  [DOI]
7.  De la Rubia L, Ruiz Villaespesa A, Cebrero M, Garcia de Frias E. Solitary rectal ulcer syndrome in a child. J Pediatr. 1993;122:733-736.  [PubMed]  [DOI]
8.  Sondheimer JM, Slagle TA, Bryke CR, Hill RB. Solitary rectal ulcer syndrome in a teenaged boy. J Pediatr Gastroenterol Nutr. 1985;4:835-838.  [PubMed]  [DOI]
9.  Godbole P, Botterill I, Newell SJ, Sagar PM, Stringer MD. Solitary rectal ulcer syndrome in children. J R Coll Surg Edinb. 2000;45:411-414.  [PubMed]  [DOI]
10.  Martín de Carpi J, Vilar P, Varea V. Solitary rectal ulcer syndrome in childhood: a rare, benign, and probably misdiagnosed cause of rectal bleeding. Report of three cases. Dis Colon Rectum. 2007;50:534-539.  [PubMed]  [DOI]
11.  Bonnard A, Mougenot JP, Ferkdadji L, Huot O, Aigrain Y, De Lagausie P. Laparoscopic rectopexy for solitary ulcer of rectum syndrome in a child. Surg Endosc. 2003;17:1156-1157.  [PubMed]  [DOI]
12.  Rao SS, Ozturk R, De Ocampo S, Stessman M. Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome. Am J Gastroenterol. 2006;101:613-618.  [PubMed]  [DOI]
13.  Contractor TQ, Contractor QQ. Traumatic solitary rectal ulcer in Saudi Arabia. A distinct entity? J Clin Gastroenterol. 1995;21:298-300.  [PubMed]  [DOI]
14.  Ertem D, Acar Y, Karaa EK, Pehlivanoglu E. A rare and often unrecognized cause of hematochezia and tenesmus in childhood: solitary rectal ulcer syndrome. Pediatrics. 2002;110:e79.  [PubMed]  [DOI]
15.  Dehghani SM, Haghighat M, Imanieh MH, Geramizadeh B. Solitary rectal ulcer syndrome in children: a prospective study of cases from southern Iran. Eur J Gastroenterol Hepatol. 2008;20:93-95.  [PubMed]  [DOI]
16.  Kennedy DK, Hughes ES, Masterton JP. The natural history of benign ulcer of the rectum. Surg Gynecol Obstet. 1977;144:718-720.  [PubMed]  [DOI]
17.  Perito ER, Mileti E, Dalal DH, Cho SJ, Ferrell LD, McCracken M, Heyman MB. Solitary rectal ulcer syndrome in children and adolescents. J Pediatr Gastroenterol Nutr. 2012;54:266-270.  [PubMed]  [DOI]
18.  Suresh N, Ganesh R, Sathiyasekaran M. Solitary rectal ulcer syndrome: a case series. Indian Pediatr. 2010;47:1059-1061.  [PubMed]  [DOI]
19.  Gabra HO, Roberts JP, Variend S, Shawis RN. Solitary rectal ulcer syndrome in children. A report of three cases. Eur J Pediatr Surg. 2005;15:213-216.  [PubMed]  [DOI]
20.  Vaizey CJ, van den Bogaerde JB, Emmanuel AV, Talbot IC, Nicholls RJ, Kamm MA. Solitary rectal ulcer syndrome. Br J Surg. 1998;85:1617-1623.  [PubMed]  [DOI]
21.  Haray PN, Morris-Stiff GJ, Foster ME. Solitary rectal ulcer syndrome--an underdiagnosed condition. Int J Colorectal Dis. 1997;12:313-315.  [PubMed]  [DOI]
22.  Kuijpers HC, Schreve RH, ten Cate Hoedemakers H. Diagnosis of functional disorders of defecation causing the solitary rectal ulcer syndrome. Dis Colon Rectum. 1986;29:126-129.  [PubMed]  [DOI]
23.  Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med. 1966;59:477-482.  [PubMed]  [DOI]
24.  Keshtgar AS. Solitary rectal ulcer syndrome in children. Eur J Gastroenterol Hepatol. 2008;20:89-92.  [PubMed]  [DOI]
25.  Blackburn C, McDermott M, Bourke B. Clinical presentation of and outcome for solitary rectal ulcer syndrome in children. J Pediatr Gastroenterol Nutr. 2012;54:263-265.  [PubMed]  [DOI]
26.  Alberti-Flor JJ, Halter S, Dunn GD. Solitary rectal ulcer as a cause of massive lower gastrointestinal bleeding. Gastrointest Endosc. 1985;31:53-54.  [PubMed]  [DOI]
27.  Bishop PR, Nowicki MJ, Subramony C, Parker PH. Solitary rectal ulcer: a rare cause of gastrointestinal bleeding in an adolescent with hemophilia A. J Clin Gastroenterol. 2001;33:72-76.  [PubMed]  [DOI]
28.  Eigenmann PA, Le Coultre C, Cox J, Dederding JP, Belli DC. Solitary rectal ulcer: an unusual cause of rectal bleeding in children. Eur J Pediatr. 1992;151:658-660.  [PubMed]  [DOI]
29.  Bishop PR, Nowicki MJ. Nonsurgical Therapy for Solitary Rectal Ulcer Syndrome. Curr Treat Options Gastroenterol. 2002;5:215-223.  [PubMed]  [DOI]
30.  Tjandra JJ, Fazio VW, Petras RE, Lavery IC, Oakley JR, Milsom JW, Church JM. Clinical and pathologic factors associated with delayed diagnosis in solitary rectal ulcer syndrome. Dis Colon Rectum. 1993;36:146-153.  [PubMed]  [DOI]
31.  Sharara AI, Azar C, Amr SS, Haddad M, Eloubeidi MA. Solitary rectal ulcer syndrome: endoscopic spectrum and review of the literature. Gastrointest Endosc. 2005;62:755-762.  [PubMed]  [DOI]
32.  Daya D, O'Connell G, DeNardi F. Rectal endometriosis mimicking solitary rectal ulcer syndrome. Mod Pathol. 1995;8:599-602.  [PubMed]  [DOI]
33.  Goei R, Baeten C, Arends JW. Solitary rectal ulcer syndrome: findings at barium enema study and defecography. Radiology. 1988;168:303-306.  [PubMed]  [DOI]
34.  Millward SF, Bayjoo P, Dixon MF, Williams NS, Simpkins KC. The barium enema appearances in solitary rectal ulcer syndrome. Clin Radiol. 1985;36:185-189.  [PubMed]  [DOI]
35.  Temiz A, Tander B, Temiz M, Barış S, Arıtürk E. A rare cause of chronic rectal bleeding in children; solitary rectal ulcer: case report. Ulus Travma Acil Cerrahi Derg. 2011;17:173-176.  [PubMed]  [DOI]
36.  Ford MJ, Anderson JR, Gilmour HM, Holt S, Sircus W, Heading RC. Clinical spectrum of "solitary ulcer" of the rectum. Gastroenterology. 1983;84:1533-1540.  [PubMed]  [DOI]
37.  Gopal DV, Young C, Katon RM. Solitary rectal ulcer syndrome presenting with rectal prolapse, severe mucorrhea and eroded polypoid hyperplasia: case report and review of the literature. Can J Gastroenterol. 2001;15:479-483.  [PubMed]  [DOI]
38.  Niv Y, Bat L. Solitary rectal ulcer syndrome--clinical, endoscopic, and histological spectrum. Am J Gastroenterol. 1986;81:486-491.  [PubMed]  [DOI]
39.  Marshall M, Halligan S, Fotheringham T, Bartram C, Nicholls RJ. Predictive value of internal anal sphincter thickness for diagnosis of rectal intussusception in patients with solitary rectal ulcer syndrome. Br J Surg. 2002;89:1281-1285.  [PubMed]  [DOI]
40.  Figueroa-Colon R, Younoszai MK, Mitros FA. Solitary ulcer syndrome of the rectum in children. J Pediatr Gastroenterol Nutr. 1989;8:408-412.  [PubMed]  [DOI]
41.  Marchal F, Bresler L, Brunaud L, Adler SC, Sebbag H, Tortuyaux JM, Boissel P. Solitary rectal ulcer syndrome: a series of 13 patients operated with a mean follow-up of 4.5 years. Int J Colorectal Dis. 2001;16:228-233.  [PubMed]  [DOI]
42.  Nicholls RJ, Simson JN. Anteroposterior rectopexy in the treatment of solitary rectal ulcer syndrome without overt rectal prolapse. Br J Surg. 1986;73:222-224.  [PubMed]  [DOI]
43.  Ashcraft KW, Garred JL, Holder TM, Amoury RA, Sharp RJ, Murphy JP. Rectal prolapse: 17-year experience with the posterior repair and suspension. J Pediatr Surg. 1990;25:992-994; discussion 994-995.  [PubMed]  [DOI]
44.  Sitzler PJ, Kamm MA, Nicholls RJ, McKee RF. Long-term clinical outcome of surgery for solitary rectal ulcer syndrome. Br J Surg. 1998;85:1246-1250.  [PubMed]  [DOI]
45.  Binnie NR, Papachrysostomou M, Clare N, Smith AN. Solitary rectal ulcer: the place of biofeedback and surgery in the treatment of the syndrome. World J Surg. 1992;16:836-840.  [PubMed]  [DOI]
46.  van den Brandt-Grädel V, Huibregtse K, Tytgat GN. Treatment of solitary rectal ulcer syndrome with high-fiber diet and abstention of straining at defecation. Dig Dis Sci. 1984;29:1005-1008.  [PubMed]  [DOI]
47.  Malouf AJ, Vaizey CJ, Kamm MA. Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome. Dis Colon Rectum. 2001;44:72-76.  [PubMed]  [DOI]
48.  Vaizey CJ, Roy AJ, Kamm MA. Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback. Gut. 1997;41:817-820.  [PubMed]  [DOI]
49.  Rao SS, Mudipalli RS, Stessman M, Zimmerman B. Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus). Neurogastroenterol Motil. 2004;16:589-596.  [PubMed]  [DOI]
50.  Zargar SA, Khuroo MS, Mahajan R. Sucralfate retention enemas in solitary rectal ulcer. Dis Colon Rectum. 1991;34:455-457.  [PubMed]  [DOI]
51.  Kumar M, Puri AS, Srivastava R, Yachha SK. Solitary rectal ulcer in a child treated with local sulfasalazine. Indian Pediatr. 1994;31:1553-1555.  [PubMed]  [DOI]
52.  Felt-Bersma RJ, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome. Gastroenterol Clin North Am. 2001;30:199-222.  [PubMed]  [DOI]
53.  Ederle A, Bulighin G, Orlandi PG, Pilati S. Endoscopic application of human fibrin sealant in the treatment of solitary rectal ulcer syndrome. Endoscopy. 1992;24:736-737.  [PubMed]  [DOI]
54.  Rau BK, Harikrishnan KM, Krishna S. Laser therapy of solitary rectal ulcers: a new concept. Ann Acad Med Singapore. 1994;23:27-28.  [PubMed]  [DOI]
55.  Keshtgar AS, Ward HC, Sanei A, Clayden GS. Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial. J Pediatr Surg. 2007;42:672-680.  [PubMed]  [DOI]
56.  Kargar S, Salmanroughani H, Binesh F, Taghipoor S, Kargar S. Laparoscopic rectopexy in solitary rectal ulcer. Acta Med Iran. 2011;49:810-813.  [PubMed]  [DOI]
57.  Beck DE. Surgical Therapy for Colitis Cystica Profunda and Solitary Rectal Ulcer Syndrome. Curr Treat Options Gastroenterol. 2002;5:231-237.  [PubMed]  [DOI]
58.  Sielezneff I, Malouf A, Cesari J, Brunet C, Sarles JC, Sastre B. Selection criteria for internal rectal prolapse repair by Delorme's transrectal excision. Dis Colon Rectum. 1999;42:367-373.  [PubMed]  [DOI]
59.  Abbas TO, Ismail A, Abdulrahman H, Ali M, Al Rikabi A. Solitary Rectal Ulcer Syndrome, a Pediatric Problem: Case Report. Oman Med J. 2011;26:208-210.  [PubMed]  [DOI]
60.  Jarrett ME, Emmanuel AV, Vaizey CJ, Kamm MA. Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow. Gut. 2004;53:368-370.  [PubMed]  [DOI]
61.  Tendler DA, Aboudola S, Zacks JF, O'Brien MJ, Kelly CP. Prolapsing mucosal polyps: an underrecognized form of colonic polyp--a clinicopathological study of 15 cases. Am J Gastroenterol. 2002;97:370-376.  [PubMed]  [DOI]
62.  Pai RR, Mathai AM, Magar DG, Tantry BV. Solitary rectal ulcer syndrome in childhood. Trop Gastroenterol. 2008;29:177-178.  [PubMed]  [DOI]
63.  Halligan S, Nicholls RJ, Bartram CI. Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse. AJR Am J Roentgenol. 1995;164:91-95.  [PubMed]  [DOI]
64.  Womack NR, Williams NS, Holmfield JH, Morrison JF. Pressure and prolapse--the cause of solitary rectal ulceration. Gut. 1987;28:1228-1233.  [PubMed]  [DOI]
65.  Alexander-Williams J. Solitary-ulcer syndrome of the rectum. Its association with occult rectal prolapse. Lancet. 1977;1:170-171.  [PubMed]  [DOI]
66.  Tandon RK, Atmakuri SP, Mehra NK, Malaviya AN, Tandon HD, Chopra P. Is solitary rectal ulcer a manifestation of a systemic disease? J Clin Gastroenterol. 1990;12:286-290.  [PubMed]  [DOI]
67.  Saadah OI, Al-Hubayshi MS, Ghanem AT. Solitary rectal ulcer syndrome presenting as polypoid mass lesions in a young girl. World J Gastrointest Oncol. 2010;2:332-334.  [PubMed]  [DOI]
68.  Keighley MR, Shouler P. Clinical and manometric features of the solitary rectal ulcer syndrome. Dis Colon Rectum. 1984;27:507-512.  [PubMed]  [DOI]
69.  Kiriştioğlu I, Balkan E, Kiliç N, Doğruyol H. Solitary rectal ulcer syndrome in children. Turk J Pediatr. 2000;42:56-60.  [PubMed]  [DOI]
70.  El-Hemaly M, El-Geidie A, Hamdy E, El-Nakeeb A, El-Hanafy E, Atef E, Sultan A, Kandil T. Solitary rectal ulcer syndrome: new hope for the patients. Egypt J Surg. 2012;31:36-40.  [PubMed]  [DOI]