Chapter 8 192 Baseline and follow-up Baseline and follow-up appointments at 1 year from baseline with the surgeon and principal investigator, an experienced pelvic floor physical therapist, consisted of a clinical examination provided through inspection to investigate the healing of the fissure. Resting anal sphincter pressure, pelvic floor muscle tone and function were measured by a careful digital rectal examination and scored as decreased, normal and increased.14,15 Pelvic floor dysfunction was defined by the presence of increased pelvic floor muscle tone and/or dyssynergia detected by digital rectal examination.14,16 Besides that, pelvic floor muscle tone was measured with EMG (mV)14 with an intra-anal probe (MAPLe® Novuqare Pelvic Health B.V. CE 0344, Rosmalen, the Netherlands). Patients were requested to fill in 3 validated self- administered questionnaires at baseline, and 1-year follow-up. To quantify the average intensity of pain during defecation, a visual analog scale (VAS) from 0 (no pain) to 10 (most intense pain) was used.17 The Proctoprom, a patient related outcome measurement was used to assess the impact of proctologic complaints on different aspects of a patient’s life and to evaluate the effect of treatment.18 To access the impact of global quality of life, the validated Dutch version of Short-Form RAND-36, Health Status Inventory, version 2 was used. 19 The RAND-36 comprises of 36 items and entails 9 subscales: physical functioning, bodily pain, role limitation due to physical health problems, vitality, general health perception, social functioning, role limitation due to emotional problems, mental health, and health change perception. Participants Men and women aged 18 years or older presenting with CAF and pelvic floor dysfunction were recruited at the Proctos Clinic in the Netherlands from December 2018 until July 2021. CAF was defined as a longitudinal ulcer in the squamous epithelium with one or more signs of chronicity including hypertrophied anal papilla, sentinel tag and exposed internal sphincter muscle with symptoms presenting longer than 6 weeks or recurrent fissures. All patients had failed conservative treatment with fiber and/or laxatives and ointment (diltiazem or isosorbide dinitrate) used for at least 6 weeks and with accurate instructions about how to apply. All patients had sufficient understanding of the Dutch language (reading and writing) and were able to complete online questionnaires. We considered patients who were not able to undergo a digital rectal examination, not
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