Chapter 6 168 All patients used ointment for at least 6 weeks prior to the treatment protocol and had applied the ointment internally at least 3 times a day. This could have positively decreased the visual analogue scale (VAS)-pain score during defecation at baseline. In addition, a large percentage of our population (51%) had fissure-related complaints for more than 6 months and only 12% had complaints for less than 2 months. The complaint duration may have influenced the (subjective) VAS-pain scores. Patients were only included in this trial when digital rectal examination could be performed. In our experience, patients tolerate the examination well after careful counselling, and are reassured that other anorectal disease is excluded. During a careful digital rectal examination, the pelvic floor muscles and anorectal anatomy and function can be evaluated properly. Additionally, we objectively evaluated pelvic floor muscle tone electromyographically with an intra-anal probe. Patients not included in the study were treated with other surgical procedures such as botulinum toxin and/or fissurectomy. The anal stretching technique prescribed in the treatment protocol were focused on the pelvic floor muscles. The stretching technique combined with soft-tissue manipulation and myofascial release is aimed at pelvic floor awareness and relaxation.3 These techniques cannot be compared to digital anal stretching treatment under sedation. Treatment with percutaneous nerve stimulation (PTNS) has been proven effective in the treatment of overactive bladder, fecal incontinence, pelvic pain 5 and nonoperative treatment of CAF.6 The tibial nerve is a mixed nerve containing L4–S3 fibers and originates from the same spinal segments as the innervations to the bladder and pelvic floor. The mechanisms of its effect are not fully elucidated, but stimulation of peripheral fibers transmits impulses to the sacral nerves and neuromodulates the lower urinary tract, rectum, and anal sphincters.5 PTNS could probably be combined with our treatment program to improve efficacy but warrants further investigation in well-designed randomized controlled trials Our study tried to fill the gap for treatment modalities between conservative management and surgery in patients with CAF and concomitant pelvic floor dysfunction. When a dog is chasing his tail, there is a lot of effort made with little effect. We believe that the positive outcomes from the use of this rehabilitative approach in patients with CAF is not time consuming and can help to improve healing of the fissure, complaint reduction, and quality of life. Additionally, the awareness by the patient of the influence of the pelvic floor muscles in anal pain might help to prevent recurrence. The PAF-study can pave the road for further research in this field.
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