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Background: Cutaneous infection by Mycobacterium ulcerans, also known as Buruli ulcer (BU), represents the third most common mycobacterial disease in the world after tuberculosis and leprosy. Data on the burden of BU disease in the Democratic Republic of Congo are scanty. This study aimed to estimate the prevalence rate and the distribution of BU in the Songololo Territory, and to assess the coverage of the existing hospital-based reporting system. Methods: We conducted a cross-sectional survey (July–August 2008) using the door-to-door method simultaneously in the two rural health zones (RHZ) of the Songololo Territory (RHZ of Kimpese and Nsona-Mpangu), each containing twenty health areas. Cases were defined clinically as active BU and inactive BU in accordance with WHO-case definitions. Results: We detected 775 BU patients (259 active and 516 inactive) in a total population of 237,418 inhabitants. The overall prevalence of BU in Songololo Territory was 3.3/1000 inhabitants, varying from 0 to 27.5/1000 between health areas. Of the 259 patients with active BU, 18 (7%) had been reported in the hospital-based reporting system at Kimpese in the 6–8 months prior to the survey. Conclusion: The survey demonstrated a huge variation of prevalence between health areas in Songololo Territory and gross underreporting of BU cases in the hospital-based reporting system. Data obtained may contribute to better targeted and improved BU control interventions, and serve as a baseline for future assessments of the control program. Author Summary: Buruli ulcer (BU) is a necrotizing bacterial infection of skin, subcutaneous tissue and bone, caused by an environmental pathogen, Mycobacterium ulcerans. BU is considered as one of the Neglected Tropical Diseases with a poorly known global prevalence, and mainly affects remote rural African communities. Data on the burden of BU disease in the Democratic Republic of Congo (DRC) are scanty. The present study is the first exhaustive survey in DRC on the frequency of BU in the community. The survey demonstrated large variations in prevalence between health areas in Songololo Territory. Moreover, our data showed that the BU cases in the hospital-based reporting system reflect only the tip of the iceberg of the true active BU prevalence. Indeed, only one in thirteen active BU cases was notified at the hospital at Kimpese in the 6–8 months prior to the survey. The present data will serve as a baseline assessment for the evaluation of control interventions in the study area, and, more generally, this study aims to raise awareness about the issue of underdetection of BU and the importance of increasing access to diagnosis and care. As such, we hope the study will contribute to improved control of BU. [ABSTRACT FROM AUTHOR]