6 PAF-study: results of a randomized controlled trial 167 The authors reply to “Pelvic floor dysfunction and chronic anal fissure: a dog chasing its tail.” Daniëlle A. van Reijn-Baggen Henk W. Elzevier Rob C.M. Pelger Ingrid J.M. Han-Geurts Dear Sir, We would like to thank Dr Pietroletti and collegues for their interest in our manuscript and the thoughtful comments concerning the role of pelvic floor physical therapy in patients with chronic anal fissure (CAF).1 Although the etiology CAF is uncertain, it is assumed that pain causes an increased sphincter tone leading to ischemia of the anal sphincter. This inhibits fissure healing, generating a vicious circle of pain and constipation thus prolonging the healing process as Pietroletti and colleagues mentioned. We hypothesized that pelvic floor dysfunction may be part of the pathophysiology and reason for unresponsiveness to some current treatment. In a retrospective study we found that a large percentage of patients with CAF had pelvic floor complaints such as dyspareunia and obstructive defecation and pelvic floor dysfunction (dyssynergia and/or increased pelvic floor muscle tone).2 Increased tone of the pelvic floor can be a primary problem or a secondary adaptation to an acute or chronic injury such as CAF or to musculoskeletal components in the pelvic floor and surrounding structures. Pelvic surgery, traumatic vaginal delivery, chronic pelvic disorders, experienced threat and (chronic) stress are found to be associated with increased pelvic floor muscle tone and related to habit, lifestyle and/ or stressful occupation. 3 The long duration of continuing fissure symptoms may lead to functional and psychosocial impairment,4 and seeking medical care is often delayed due to embarrassment. These underlying factors should be kept in mind when treating patients with CAF. Although the title may not fully cover the whole scope of the manuscript, we think that the pelvic floor anal fissure (PAF)-study shows a broader perspective on patients with CAF. As mentioned in both the study protocol and in the abstract, the primary objective of our study was to establish the effectiveness of pelvic floor physical therapy in the treatment of CAF and pelvic floor dysfunction such as dyssynergia and/or increased pelvic floor muscle tone.
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