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A detailed interview disclosed her habit of finger evacuation of the rectum. A diagnosis of self inflicted rectal ulcer was suspected. Avoidance of rectal digitation was advised. Follow up colonoscopy showed that the ulcer had healed, indicating that self inflicted injury was the aetiology.

Rectal ulcer is an infrequent pathology associated with various disorders, including inflammatory bowel disease, infectious proctitis, mucosal prolapse syndrome (MPS), ischaemic colitis, and neoplasms. Symptoms of MPS may include a sense of incomplete rectal evacuation necessitating digital manipulation. Therefore, in addition to the pathological examination, detailed history is very important to differentiate self inflicted rectal ulcer, especially from MPS. Enquiry about finger evacuation may be better asked without the presence of patients’ family members or other medical staff. In conclusion, with an emphasis of the importance of detailed history, self inflicted rectal ulcer should be recognised as an important differential diagnosis for the management of anorectal diseases.

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