PAF-study, long term follow-up 191 8 Introduction Background and objectives Chronic anal fissure (CAF) is a frequent and disabling anorectal disorder. Optimal management of CAF is quite challenging, mainly because of its recurrent nature. Initial conservative therapy includes normalization of the defecation pattern by a fiberenriched diet to ensure the regular passage of soft stools.1 Treatment with ointments is aimed at reducing elevated internal sphincter tone for which nitro-glycerine as well as calcium channel blockers achieve good results.2 When conservative treatment fails local botulinum toxin injections and/or fissurectomy and lateral internal sphincterotomy are possible treatment options. Botulinum toxin is often used for CAF, but has a recurrence rate of 41.7%.3 In the Netherlands the first step of surgical treatment is fissurectomy.4 The long term-effect of fissurectomy has been proven successful with recurrence rates between 6 and 12%,5,6 although the mean time for obtaining wound healing is about 10 weeks.6 Lateral internal sphincterotomy remains the surgical treatment of choice for fissures that are refractory to medical treatment and is recommended in guidelines.7,8 The recurrence rate of lateral internal sphincterotomy is low (6.9%),3 however there is a potential risk of incontinence.3,9-11 To fill the gap in treatment modalities between conservative management and surgery we recently performed a randomized controlled trial to investigate the effect of pelvic floor physical therapy in the treatment of CAF (PAF-trial). This trial demonstrated that pelvic floor physical therapy was effective in patients with CAF and concomitant pelvic floor dysfunction. Patients had clinically relevant and significant improvements in all outcomes, clinical healing of the fissure, pain ratings, diminished pelvic floor dyssynergia and complaint reduction.12 The aim of this study was to determine the outcomes of the PAF-trial and fissure recurrence at 1-year follow-up. Materials and Methods Study design This was a study of the long-term results of PFPT, originally evaluated in a single -centre randomized controlled trial (PAF-trial).12 The PAF-trial included 140 patients with CAF and pelvic floor dysfunction. Patients were randomized to 2 study groups, an intervention group starting immediately after inclusion with PFPT and a control group receiving postponed PFPT after 8 weeks after inclusion. The present study was a long-term follow-up, using the same outcomes as in the RCT.13
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