Two complementary physiologic tests for SRUS
are anorectal manometry and defecography. Anorectal manometry often shows evidence of dyssynergia and rectal hypersensitivity in patients
with SRUS.20,21 Hypersensitivity may produce a
sensation of incomplete evacuation, which in turn
results in excessive straining. Defecography may
reveal rectal mucosal intussusception or overt rectal prolapse. The patient in this case had evidence
of rectal hypersensitivity on anorectal manometry
along with excessive perineal descent on defecography.
• What are the treatment options for SRUS?
Treatment of SRUS is not standardized. The options include topical medical therapy, biofeedback,
and surgery. Uncontrolled studies have suggested that 5-aminosalicylic acid enema,22 sucralfate
enema,23 steroid enema,24 and fibrin glue25 may
improve symptoms. Patients who fail topical therapy
and have evidence of dyssynergia on anorectal
manometry should receive biofeedback therapy. A
case-control study of biofeedback involving 11 patients with refractory SRUS and 15 healthy controls
showed improvement in anorectal function, including dyssynergia.21 At follow-up endoscopy, 36%
had complete mucosal healing and more than 50%
showed partial healing. In a study involving 16 patients
with SRUS and 26 healthy controls, Jarrett et al26
showed that 75% of patients who underwent biofeedback therapy had improved and 31% had ulcer
resolution. Surgical therapy should be considered in
rare patients who are refractory to medical therapy.
The Delorme procedure is commonly performed
with a success rate of 42% to 100%.27
The case patient underwent biofeedback therapy,
and after 5 sessions had complete healing of the
lesion and resolution of rectal bleeding and bowel
CASE PRESENTATION 3
Initial Presentation and History
A 75-year-old woman is referred to a gastroenterologist with complaints of incomplete stool evacuation and intermittent fecal seepage. She passes stools daily but sits on the toilet for
15 to 20 minutes, and after straining will pass only
a small amount of stool. She describes stools as
type 4 on the Bristol scale with no blood or mucus.
One to 2 hours after a bowel movement, she experiences some wetness in the perineal region and
upon checking often notices that a tablespoon full
of stool material has leaked out. Sometimes, she
will pass another large stool. She denies any leakage of stool while sleeping. Occasionally, she has
urgency and leaks stool before reaching the toilet. In
the past, she has used digital maneuvers to facilitate
stooling. This problem has interfered with shopping,
socializing, and taking vacations.
Figure 2. Endoscopic image of an irregular ulcer base covered
with fibrinous exudate in the rectum, a finding typical of solitary
rectal ulcer syndrome.