PAF-study, long term follow-up 203 8 A clinical follow-up could be beneficial to re-evaluate and to repeat the learned skills.28 In our trial we scheduled at least 2 follow-up appointments after the treatment period in 1 year. This could have positively influenced the outcome of treatment. Besides that, a clinical follow-up could reinforce the adherence rate which are described in behavioural interventions such as PFPT. Important barriers to adherence are difficulties remembering to do the exercises and finding time to do them.29 The recurrence rate in our study was 15.5%, which is low compared to other current treatments in CAF. When clinical factors related to recurrence were analysed, gender, duration of complaints, location of the fissure and prior treatment were not significantly related to the long-term recurrence. In half of our patients the recurrence was influenced by stool changes. Special attention should be paid to avoid constipation and remain a good lifestyle to avoid recurrence. The use of extra 20-25gr/d of fiber should be recommended to ensure avoidance and constipation.30,31 The first results from our study13 confirmed that both groups significantly improved at 20 weeks follow-up on all outcomes, although the PFPT-group improved faster than the postponed group. At 1-year follow-up, no significant difference was found between groups, even though a higher recurrence rate (20.5%) was found in the postponed PFPT group. More patients from the postponed PFPT-group received botulinum toxin (3.8% vs 9.1%). Thus, we would recommend starting with PFPT as soon as possible after at least 6 weeks of using ointment (diltiazem or isosorbide di-nitrate) and good regulation of the defecation pattern. Seven patients in our study developed a superficial fistula during the trial. Suppurative lesions are commonly found with CAF and mostly due to diseases of the anal glands, or the result of infection of the lymphoid tissues, which become chronically infected.32 It is unknown which proportion of fistulas are due to a fissure and at what time lapse it becomes evident. In the Netherlands, only 57% of the gastrointestinal surgeons scheduled a physical follow-up after 6-8 weeks and 46% scheduled telephone call or according to the needs of the patients.4 The development of other anorectal complaints could therefore be missed. Conservative management of chronic anal fissure is associated with significant improvement in patients related outcome scores. In our study we used the Proctoprom to detect changes over time, the patient’s state of health measures and the effect of treatment.18 The study showed a significant effect of disease burden from the patient’s point of view at long-term follow-up. In a study by Wilson et al.33 on bowel function
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