PAF-study: results on quality of life 183 7 baseline. Patients with healed fissures after treatment, reported an improvement in bodily pain, vitality, general health, and mental health. The PAF-study10 found that the fissure was healed in 60% of all patients at 20-week follow-up. Significant lower scores were found in patients with non-healed fissures in the domains, bodily pain, social functioning, and emotional role at that time-point. In a study of Bagul et al.29 in patients with CAF who received botulinum toxin injections, pain scores improved in 74% of the patients. QoL improved in patients in the domains of physical functioning, bodily pain, social functioning, and mental health. The study demonstrated that pain was a significant factor influencing the outcome of QoL scores. Another study investigating QoL after lateral internal sphincterotomy in 58 patients30 found improvement in pain symptoms although not all domains of health related QoL were similarly positively affected. Smaller gains were reported among younger participants, women, participants with no comorbidities and those participants who waited the longest for their surgery. Patients with CAF in our study scored overall lower than the reference group of the Dutch population. One of the reasons could be the chronicity of the problem. In our population, 65% of the patients had complaints for more than 6 months, which would have a negative influence on the patient, family members and other relations.31 Other factors influencing the outcome of treatment should be investigated in further studies with a long-term follow-up. The conclusions of this study are strengthened by the response rate of 71% at baseline, the high sample size and prospective design of the study. We enrolled patients of all ages and both sexes from different parts of the Netherlands. Thus, the results may be generalizable to the CAF population at large. This study has some limitations. Currently, there is no disease-specific tool for assessing QoL in patients with CAF and therefore a generic instrument was used. The RAND36 was chosen because it is one of the most used questionnaires measuring QoL, and it is translated in Dutch.13 Its reliability has been proven in a post-rehabilitation Dutch population32 but may not be specific enough to fully analyze the QoL in patients with CAF. The non-response rate was 31% at 20-week follow-up. This may have caused bias if non-or partial- respondents differ from respondents as concerns QoL or its determinants or confounders.33 Reasons for non-completion at 20-week follow-up were surgery including Botulinum toxin, fissurectomy, fistulotomy, sclerodermy and other surgery (breast cancer). Other reasons were COVID-19, pregnancy, loss
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