Chapter 9 214 Chapter 1 General introduction Anorectal disorders are common in general practice and the incidence of chronic anal fissure is 2.5 cases per 1000 persons in the Netherlands.1 This thesis covers the anatomical and pathophysiological aspects of CAF faced during clinical practice with the focus on treatment by pelvic floor physical therapy alongside current management. In chapter 1 we outlined the symptoms, pathogenesis, diagnostics, and management of CAF. A chronic anal fissure (CAF) refers to a longitudinal ulcer or tear in the squamous epithelium, generally located in the posterior midline with symptoms present for longer than 4-6 weeks or recurrent fissures.2,3 The classical symptom is pain during defecation, which may persist for hours,4,5 and has a significant impact on quality of life.6 Although some debate exists on the pathogenesis of CAF, it is assumed that pain causes an increased anal sphincter tone leading to ischemia which inhibits fissure healing, generating a vicious circle of pain and constipation.7-10 Pelvic floor dysfunction e.g., dyssynergia and/or increased pelvic floor muscle tone may also be an underlying cause and part of the pathophysiology and a reason for unresponsiveness to treatment. We described the importance of performing a digital rectal examination including examination of the pelvic floor muscles and a comprehensive evaluation of the pelvis and surrounding structures to determine the underlying cause of pain and pelvic floor dysfunction.11,12 Recent technological advances (electromyography and anorectal manometry) were described in this thesis. Electromyography can be used to assess motor control patterns, coordination, and pelvic floor muscle function.13 Manometry can be used as a component of clinical evaluation for patients in whom additional management strategies are considered.14 According to current guidelines, the initial conservative management is comprised of fibre intake and/or use of laxatives, toilet behaviour, lifestyle advice, sitz baths, and ointments. Pelvic floor physical therapy (PFPT) is an important part of a multidisciplinary treatment approach and could be added to conservative management. When conservative treatment fails, botulinum toxin can be applied.15,16 which is a safe alternative to surgery.17 Various surgical procedures are possible such as fissurectomy and lateral internal sphincterotomy. Although lateral internal sphincterotomy is the
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