title: Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse.
abstract: OBJECTIVE
  Solitary rectal ulcer syndrome is characterized by rectal bleeding, tenesmus, and difficult evacuation. Evacuation proctography can be used in patients with solitary rectal ulcer syndrome to diagnose associated internal or external rectal prolapse and delayed or incomplete rectal emptying. The objective of this study was to determine the proctographic abnormalities and the frequency of rectal prolapse and incomplete or delayed emptying in a large group of patients with solitary rectal ulcer syndrome.
  
  
  METHODS
  Proctographic examinations of 53 patients with histologically proved solitary rectal ulcer syndrome were reviewed retrospectively. Evacuation proctography was done by a standard technique. The rate and completeness of rectal emptying and structural abnormality of the rectum were recorded. Comparison was made with a control group of 20 subjects who had no anorectal symptoms.
  
  
  RESULTS
  Fourteen patients (26%) with solitary rectal ulcer syndrome had rectal irregularity at rest compared with none in the control group. Rectal prolapse developed on evacuation in 36 patients (68%) with solitary rectal ulcer syndrome: internal prolapse in 24 patients (45%), and external prolapse in 12 (23%). Descent of the pelvic floor on evacuation was greater in the solitary rectal ulcer syndrome group (median, 4.4 cm; range, 0-10.0 cm) than in the control group (median, 3.3 cm; range, 0.6-5.3 cm; p = .006). Thickened rectal folds were seen in 11 (55%) of 20 patients with solitary rectal ulcer syndrome examined with posteroanterior proctography. Evacuation was prolonged and incomplete in patients with solitary rectal ulcer syndrome (median, 15 sec; range, 3-60 sec) compared with control subjects (median, 10 sec; range, 3-30 sec; p = .012). All control subjects evacuated more than two thirds of the contrast material in less than 30 sec compared with only 41 patients with solitary rectal ulcer syndrome (77%). Overall, evacuation proctography disclosed delayed or incomplete emptying and/or rectal prolapse in 40 patients (75%) with solitary rectal ulcer syndrome compared with two control subjects who showed low-grade internal rectal prolapse only (p < .0001).
  
  
  CONCLUSIONS
  Solitary rectal ulcer syndrome is significantly associated with prolonged and incomplete evacuation and with an increased prevalence of internal and external rectal prolapse.
authors.affiliation: Department of Radiology, St. Mark's Hospital for Diseases of the Colon and Rectum, London, England.
authors.forename: S
authors.initials: S
authors.lastname: Halligan
authors.forename: R J
authors.initials: RJ
authors.lastname: Nicholls
authors.forename: C I
authors.initials: CI
authors.lastname: Bartram
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003672:Defecation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012002:Rectal Diseases / Q000000981:diagnostic imaging* / Q000503:physiopathology; D012005:Rectal Prolapse / Q000000981:diagnostic imaging*; D012007:Rectum / Q000000981:diagnostic imaging* / Q000503:physiopathology; D012189:Retrospective Studies; D014456:Ulcer / Q000000981:diagnostic imaging / Q000503:physiopathology