The purpose of this study was to evaluate the diagnostic accuracy of contrast-enhanced endorectal MRI for the staging of rectal adenoma versus rectal carcinoma in correlation to findings from biopsy and histopathology. Ten volunteers and 20 patients underwent body-coil and endorectal MRI (1.5T supraconducting unit) using plain, T1-weighted (w) T2-w SE and TSE-w sequences, a dynamic Gd-DTPA enhanced protocol (turboFLASH), and postcontrast T1-w-SE sequences. Histopathological correlation via biopsy (n = 10) and surgical resection (n = 19) were conducted for all patients. An independent, two-observer, reader evaluation was performed and qualitative and quantitative data calculated. In volunteers and all patients endorectal MRI reliably delineated normal wall layers. Rectal adenomas (n = 7) were identified by a visualization of an intact muscularis mucosae, a homogeneous inner structure, and a significant contrast enhancement. T1 carcinomas (n = 4) were best identified in dynamic turboFLASH sequences by delineation of an intact muscularis propria. The visualization of contrast-enhancing tumor tissue was indicative of a T2 carcinoma (n = 4). All T3 (n = 3) and T4 (n = 2) carcinomas were correctly staged on dynamic and static MRI. The endorectal MRI stage agreed with the staging results from pathological study in 16 of 20 (80%) patients. Endorectal surface coil MRI provides reliable data for the preoperative staging and evaluation of rectal lesions.