Solitary Rectal Ulcer Syndrome: An Exceptional Entity in the Elderly

Solitary ulcer of the rectum or better the syndrome of solitary rectal ulcer syndrome (SRUS) is a rare benign pathology with a prevalence estimated at 1/100,000 inhabitants. It mainly affects young patients with a maximum incidence between the third and fourth decade of life, but can be seen at any age. It remains exceptional in the elderly with only few sporadic cases in the world literature. We report an original case of SRUS occurring in a 70-year-old man with no particular pathological history, who was explored for rectal bleeding with anal pain that had been evolving for two years. As rare as it is, this entity deserves to be known by any healthcare professional caring for elderly subjects because can sometimes progress unfavorably with severe and even fatal complications such as massive bleeding and perforation.


Introduction
Solitary ulcer of the rectum or better the solitary rectal ulcer syndrome (SRUS) is a rare benign pathology [1,2]. Its prevalence has been estimated at 1/100,000 inhabitants with a slight female predominance [2,3]. This uncommon disorder of the rectum is little known by health professionals, and very difficult to manage with no consensus on its treatment [1][2][3]. The typical endoscopic presentation of SRUS is the single ulcer on the anterior wall of the rectum; however other less specific and more challenging aspects may be noted such as multiple rectal ulcers, mucosal hyperemia, giant ulcers, and polypoid lesions [1][2][3].
The SRUS is a disease of young adults with a maximum incidence between the third and fourth decade of life [1][2][3][4]. The forms of the child and the elderly remain exceptional [3,4]. They pose a real diagnostic and therapeutic challenge for practitioners; particularly in the elderly where the SUSR can mimic a carcinoma of the rectum [5] and be a cause of sometimes serious digestive bleeding [6]. In addition, this syndrome significantly affects the quality of life of these patients [4][5][6].
We report the original observation of a solitary ulcer of the rectum occurring in a 70-year-old man.

Case presentation
A 70-year-old man, with no particular pathological history, was admitted to our department for exploration of rectal bleeding with anal pain that had been evolving for two years. The somatic examination was unremarkable. Examination of the anal margin showed anal mucous prolapse on exertion. The digital rectal examination revealed a sphincter hypotonia on voluntary contraction.
Colonoscopy showed an isolated ulceration measuring 2 × 3 cm and located 10cm from the anal margin with an erythematous rim, and prolapse of the rectal mucosa. The remainder of the colonoscopy was normal. Histological examination of the biopsies taken from the ulceration showed a nonspecific inflammatory change. Surgical excision was performed under general anesthesia after anal dilation. Pathological examination of the resection piece was consistent with the diagnosis of a solitary ulcer of the rectum. No malignant cells, granulomas, or microabcesses were noted. The evolution was favorable without subsequent recurrence.
It is a rare entity that mainly affects young patients but can be seen at any age [3,4]. It remains exceptional in the elderly with only few sporadic cases in the world literature [8,9].
Usually considered a benign disease, SRUS can sometimes progress unfavorably with severe and even fatal complications (massive bleeding and perforation) [14,15].

Conclusion
As rare as it is, this entity deserves to be known by any healthcare professional caring for elderly subjects. It should be discussed in front of any defecation disorder, even minor. Only early and appropriate diagnosis and management can improve the prognosis of this disease, which risks compromising life in the elderly..