Rectal Ulcers: Symptoms, Types, Causes and Treatment

Rectal ulcers are a lesser-known but impactful condition affecting the lower digestive tract. They can cause distressing symptoms like rectal bleeding, pain, and changes in bowel habits, often leading to significant anxiety for patients. Despite their name, these ulcers are not always solitary, nor are they always true ulcers—they can also appear as polyp-like or inflamed lesions. Understanding the full spectrum of rectal ulcers, from their symptoms to treatment options, can help patients and healthcare providers make informed decisions and improve quality of life.

Symptoms of Rectal Ulcers

Rectal ulcers present with a distinct set of symptoms that can vary in severity and frequency. Early recognition is crucial, as these symptoms often overlap with other gastrointestinal disorders. Many patients find themselves struggling with persistent rectal bleeding or bothersome mucus discharge, while others experience discomfort, pain, or changes in bowel habits. The key is to recognize these patterns and seek medical evaluation early.

Symptom	Description	Frequency/Notes	Source(s)
Rectal Bleeding	Bright red blood, often after straining	Most common symptom	1 3 4 5 8
Mucus Discharge	Copious mucus from rectum	Frequently reported	1 2 4 5
Constipation	Difficulty passing stools	Common, may alternate with diarrhea	3 4 8
Straining	Excessive effort during defecation	Highly prevalent	2 4 5
Tenesmus	Urge to defecate with little output	Less common	2 4 5
Anal/Rectal Pain	Discomfort or pain in rectal area	Variable frequency	1 2 4 5
Incomplete Evacuation	Feeling of not fully emptying	Noted in many patients	2 4
Diarrhea	Loose stools, sometimes alternating	Occurs in a subset of patients	3 4

Table 1: Key Symptoms

Common Symptoms

The hallmark symptom of rectal ulcers is rectal bleeding, which is frequently bright red and may be noticed on toilet paper or in the toilet bowl after straining. Mucus discharge is another common complaint, often leading to discomfort and embarrassment for patients. Constipation and excessive straining at stool are also prevalent, as is the sensation of incomplete evacuation—patients may feel the urge to defecate repeatedly, often with little relief 1 2 3 4 5 8.

Less Frequent or Overlooked Symptoms

Some individuals also report tenesmus (a persistent urge to defecate), anal or rectal pain, abdominal cramping, and even episodes of diarrhea. These symptoms can overlap with other gastrointestinal conditions, making diagnosis challenging. In children, symptoms such as rectal pain or cramping may be underreported or mistaken for more common pediatric ailments 4 5.

Impact on Daily Life

The persistent nature of these symptoms can significantly affect daily routines, leading to anxiety, social withdrawal, and a decreased quality of life. Chronic bleeding can result in anemia, while ongoing constipation or straining may exacerbate the underlying problem, creating a viscous cycle that is hard for patients to break without intervention 1 2 4 5.

Types of Rectal Ulcers

Rectal ulcers are not a uniform entity. While the term “solitary rectal ulcer” is frequently used, the reality is more complex, with ulcers presenting in a variety of forms and patterns. Understanding these types helps clinicians tailor diagnosis and treatment strategies to individual patients.

Type	Description	Prevalence/Notes	Source(s)
Solitary Ulcer	Single ulcer, usually anterior rectal wall	Seen in about 20-44% of cases	1 2 3 4 8
Multiple Ulcers	More than one ulcer present	Observed in 39% of some series	1 2 3
Polypoid	Polyp-like or nodular lesions	Up to 17% of cases	2 3 4 8
Erythematous Mucosa	Reddened, inflamed mucosa	Less common	3 4
Non-ulcerative	Histological changes without visible ulcer	Around 13–20% of cases	1 2 3

Table 2: Types of Rectal Ulcers

Classic Solitary Ulcer

The most “classic” form is a single ulcer located on the anterior wall of the rectum, typically 5-13 cm from the anal margin. Despite the name, this is not the only presentation 1 2 3 8.

Multiple and Polypoid Lesions

In many patients, there are multiple ulcers or even polypoid (polyp-like) and nodular lesions. These can be mistaken for other diseases such as inflammatory bowel disease or rectal cancer 2 3 4 8.

Erythematous and Non-ulcerative Forms

Some cases present only with an inflamed, reddened mucosa (erythematous) or with no visible ulcer at all. In these non-ulcerative cases, diagnosis can only be made with histological examination, which reveals the underlying tissue abnormalities characteristic of rectal ulcer syndrome 1 2 3 4.

Pediatric Considerations

In children, the spectrum of lesion types is similar, but polypoid and non-ulcerative forms may be more easily confused with juvenile polyps or other benign conditions 4 5.

Causes of Rectal Ulcers

The causes of rectal ulcers are complex and multifactorial. Several risk factors and mechanical processes have been identified, but the condition remains somewhat enigmatic. Recognizing the underlying cause is key to effective management.

Cause	Mechanism/Trigger	Notes	Source(s)
Rectal Prolapse	Mucosal or full-thickness prolapse	Most common underlying factor	1 2 3 6 8 9 10
Chronic Straining	Excessive effort at defecation	Both a cause and consequence	2 3 4 5 6 8 10
Pelvic Floor Dysfunction	Abnormal muscle coordination	Often coexists	2 3 6 10
Direct Trauma	Digital evacuation, enemas, etc.	Can cause mucosal injury	8 9
Ischemia	Reduced blood flow, atherosclerosis	Less common	8 9
Medication (Ergotamine)	Suppository-induced ulceration	No prolapse, heals if stopped	7

Table 3: Causes of Rectal Ulcers

Mechanical Factors: Prolapse and Straining

The leading cause of rectal ulcers is rectal mucosal or full-thickness prolapse. The repeated prolapse of the rectal wall, especially under high pressure from straining, leads to ischemia (lack of blood flow) and direct trauma to the mucosa. Overactivity of the anal sphincter during evacuation further increases intrarectal pressure, worsening the injury 1 2 3 6 8 9 10.

Pelvic Floor Disorders and Dysfunction

Abnormalities in pelvic floor muscle coordination—such as paradoxical contraction during defecation—are frequently seen in patients. These dysfunctions interfere with normal evacuation, leading to chronic straining and increased risk of ulceration 2 3 6 10.

Direct Trauma and Ischemia

Other causes include direct trauma (from digital evacuation or frequent enemas), and, less commonly, localized ischemia due to atherosclerosis. These factors can damage the rectal lining, resulting in ulcer formation 8 9.

Medication-Induced Ulcers

In rare cases, rectal ulcers can be caused by specific medications, such as suppositories containing ergotamine tartrate. These ulcers differ from classic rectal ulcers in that they lack prolapse and resolve quickly once the offending medication is discontinued 7.

Treatment of Rectal Ulcers

Managing rectal ulcers requires a tailored, stepwise approach. While some patients respond to conservative measures, others may need more advanced interventions. The goal is to relieve symptoms, heal the ulcer, and prevent recurrence or complications.

Treatment	Approach/Intervention	Notes/Outcome	Source(s)
Lifestyle/Conservative	Bulk-forming agents, hydration, avoid straining	First-line, often effective	8 10 11 12
Biofeedback	Pelvic floor retraining	Improves defecatory function	10 11 12 14
Topical Therapy	Rectal enemas (anti-inflammatory)	More effective with biofeedback	11 14
Laxatives	Stool softeners, osmotic agents	Reduce constipation/straining	12
Surgery	Rectopexy, mucosectomy, colectomy	For refractory/prolapsed cases	1 8 9 10 11 12
Argon Plasma Coagulation (APC)	Endoscopic ablation	For bleeding, refractory cases	13
Discontinue Offending Drugs	Stop ergotamine, NSAIDs	Effective for drug-induced cases	7 9

Table 4: Treatment Strategies

Conservative and Lifestyle Measures

The cornerstone of treatment is conservative management—encouraging a high-fiber diet, using bulk-forming agents, maintaining adequate hydration, and avoiding straining during defecation. These measures are first-line and are often sufficient in mild or early cases 8 10 11 12.

Biofeedback and Pelvic Floor Rehabilitation

Biofeedback therapy is a key intervention, especially in patients with pelvic floor dysfunction. It teaches patients how to properly coordinate pelvic muscles during defecation, reducing straining and promoting healing. Studies show that combining biofeedback with topical rectal therapies, such as anti-inflammatory enemas, yields better outcomes than biofeedback alone 10 11 12 14.

Topical and Medical Therapy

Topical therapies, such as corticosteroid or sulfasalazine enemas, can reduce local inflammation and support mucosal healing. These are typically used in combination with biofeedback for optimal results 11 14.

Laxatives and Stool Softeners

Laxatives and stool softeners are frequently prescribed to manage constipation and prevent excessive straining. They are a mainstay in ongoing management, especially where lifestyle changes alone are insufficient 12.

Surgical Interventions

When conservative and medical measures fail—especially in the presence of persistent rectal prolapse—surgical options like rectopexy (to anchor the rectum) or mucosectomy may be considered. Surgery is generally reserved for severe or refractory cases 1 8 9 10 11 12.

Argon Plasma Coagulation (APC)

For patients with persistent bleeding or refractory ulcers, argon plasma coagulation (APC) has emerged as a promising endoscopic therapy. APC can help control bleeding and promote ulcer healing, especially in patients unresponsive to standard treatment 13.

Medication-Induced Ulcers

If a medication (such as ergotamine suppositories) is identified as the cause, discontinuation typically leads to rapid healing of the ulcer 7 9.

Long-term Outlook

Despite treatment, some patients may experience persistent or recurrent symptoms. A multidisciplinary approach and regular follow-up are essential for optimizing outcomes and improving quality of life 1 2 3 12.

Conclusion

Rectal ulcers are a complex and often misunderstood condition. Timely recognition and a comprehensive, individualized approach to management are key to improving patient outcomes. Here’s a summary of the main points covered:

• Symptoms: Rectal bleeding, mucus discharge, constipation, straining, and pain are common, but symptoms can vary widely.
• Types: Not all rectal ulcers are solitary; multiple, polypoid, and non-ulcerative forms exist.
• Causes: Most frequently due to rectal prolapse and chronic straining; pelvic floor dysfunction, trauma, ischemia, and medications can also play a role.
• Treatment: Stepwise approach—conservative management and biofeedback are first-line; topical therapies, laxatives, and surgery are used for refractory cases; APC is promising for persistent bleeding.

With increased awareness and a targeted strategy, most patients can achieve symptom relief and improved quality of life. If you or someone you know is experiencing rectal bleeding or related symptoms, prompt medical evaluation is essential for early diagnosis and effective treatment.