6 PAF-study: results of a randomized controlled trial 147 Introduction Background and objectives Chronic anal fissure (CAF) is one of the most common proctological problems. It causes significant morbidity and has a large impact on quality of life.1,2 An anal fissure refers to a longitudinal ulcer in the squamous epithelium, generally located in the posterior midline.3 The classical symptom is pain during defecation, which may persist for hours.3,4 The exact pathogenesis of CAF is debatable. Passing of hard stools or sudden evacuation of liquid stool can lead to mucosal damage, resulting in an overreaction of the external anal sphincter (EAS) continence reflex and an increase of basal resting pressure. This could lead to spasm, thus leading to reduced blood flow and ischaemia, which prevents CAF from healing.5-8 Defecation is a complex function. Normal defecation requires anorectal synchronisation, an intact rectal sensation and perception, a contraction of the abdominal muscles and relaxation of the EAS and puborectalis muscle. To evacuate stool, it is essential that the puborectalis muscle relaxes for straightening the anorectal angle.9 When the pelvic floor muscles do not relax or even contract (dyssynergia) during attempted defecation this could result in an increase in the anorectal angle and hence prohibits the normal passage of stool.10 Dyssynergia and increased pelvic floor muscle tone are likely to be factors contributing to delayed healing and pain in patients with CAF.11,12 Initial treatment of CAF is based on conservative management with fiber and /or laxatives to alleviate constipation. Treatment with ointment is directed toward relieving internal sphincter spasm, thus improving circulation and pain relief.13 If unresponsive to conservative management including ointment, botulinum toxin injections may be considered, however this is associated with recurrence rates of 18-50%.3,14,15 Another option and currently the gold standard of surgical intervention is lateral internal sphincterotomy.16 Nevertheless, its potential risk of causing incontinence, 3.4 - 14%, should be kept in mind when considering this treatment.14,16-18 In patients with CAF, who have also been diagnosed with pelvic floor dysfunction, pelvic floor physical therapy (PFPT) may add to adequate treatment. The aim of PFPT is to increase awareness and proprioception, to improve muscle relaxation, elasticity of the pelvic floor muscles, to restore abdominopelvic coordination, and reduce pain.19,20 PFPT including biofeedback therapy has already been proven effective in the treatment of increased pelvic floor muscle tone and dyssynergia,19,21-24 but has not been investigated in patients with CAF.
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