Chapter 6 160 pressure in the presence of anal sphincter defects,42 but a subgroup analysis showed high anal sphincter pressure in 90% of these women. In contrast, high anal sphincter pressure was found in 87% of posterior fissures. This outcome is quite interesting, although it should be mentioned that we investigated anal sphincter pressure with digital rectal examination and not with manometry. The presence of pain and an alteration of anal sensibility,43 could blur correct anal sphincter pressure and result in a higher pressure. Several studies about comparison between digital rectal examination show an overall good agreement in pressures with manometry but the results are not consistent.43-47 These results should be interpreted with care. Dyssynergia of the pelvic floor was found in a large percentage (72.9%) of our patients at baseline. Subgroup analyses showed less dyssynergia (56%) in patients with low/normal pressures compared to patients with high anal sphincter pressures (76%). This is comparable to the study of Jain et al.,48 in which 426 patients with fecal evacuation disorders were investigated with anorectal manometry. Dyssynergia was more common in patients with CAF. Whether CAF is secondary to dyssynergic defecation or responsible for an abnormal defecation pattern is still under debate. Treatment with biofeedback for dyssynergia is highly recommended in clinical guidelines 4,23 and was also successful in our study, considering the improvement in dyssynergic pattern of the pelvic floor after treatment, although 22% of the patients did not improve. Dyssynergia is affected by alterations of the chest, abdominal wall and vertebral column and pelvic floor that may be functional, anatomical, or behavioural which may influence the outcome of PFPT. 20,49 It is important to perform a comprehensive evaluation of these alterations with a multidimensional approach to define which patients will benefit most from PFPT.50 The Proctoprom was used to detect changes over time, the patient’s state of health measures and the effect of treatment.31 This study showed a significant effect of disease burden and treatment from the patient’s point of view. Although the PFPT group improved in all the outcome measures, patients in the control group also improved significant in pain and Proctoprom-scores, at first follow-up. The first step in treatment is re- education and understanding defecation disorders.51 Probably the information all patients receive about their complaints, instruction about toilet behaviour and lifestyle advice contribute to this improvement. An evident decrease of pelvic floor muscle tone, improvement of fissure healing and pelvic floor function at 20-week follow-up indicated that patients from the postponed
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