Chapter 8 202 Discussion Principal findings This is the first study with a long-term follow-up demonstrating the efficacy of PFPT in patients with CAF and pelvic floor dysfunction. The results from this followup study show that PFPT resulted in significant and clinically relevant long-term improvement regarding mean resting tone of the pelvic floor, recurrence rate, changes in dyssynergia of the pelvic floor, pain, complaints, and quality of life. Furthermore, the improvement at the short-term follow-up at 20 weeks12 was sustained at the longterm follow-up for all outcomes. Pelvic floor muscle tone and function measured with EMG-biofeedback decreased from baseline to follow-up and demonstrated an effective and efficient treatment modality. Biofeedback is the mainstay in the treatment of anorectal dysfunctions21,22 and is commonly utilized in PFPT. In this trial, we established that EMG-biofeedback in CAF with pelvic floor dysfunction yields a high percentage of clinical benefit, in the short, medium- and long-term period. The long-term efficacy of PFPT including biofeedback on dyssynergia has already been proven in randomized control trials in patients with constipation,23,24 although no long-term studies were performed in patients with CAF. Pelvic floor muscle tone, based on digital rectal examination significantly decreased from baseline to follow-up after 1 year. A comprehensive careful digital rectal examination is an important topic to obtain information on anorectal anatomy and function.15,25 Although digital rectal examination to investigate muscle tone and dyssynergia is recommended in clinical guidelines,8,14 only 23% of the surgeons investigate the pelvic floor during digital rectal examination in patients with CAF.4 In our study we found that a large percentage of the patients had an increased pelvic floor muscle tone and this could be a contributing factor in the pain patients experience after defecation.26 It is therefore important to investigate the pelvic floor muscles during digital rectal examination in patients with CAF. In almost 75% of the patients, dyssynergia of the pelvic floor was found at baseline. Pelvic floor dyssynergia, is thought to be a learned and acquired behavioral disorder of defecation, where an inability to coordinate the abdominal, recto-anal, and pelvic floor muscles during attempted defecation exists.27 Although patients improved in their dyssynergic pattern, it is possible that this learned behavior does tend to lose the benefit over a period of time 28 which could influence fissure recurrence. It is important to encourage patients to continue practicing their exercises and learned techniques.
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