Chapter 9 220 After 1 year, the fissure recurred in 15 patients (15.5%). VAS-pain significantly decreased from baseline to follow-up (mean estimated difference 4.16; 95% CI, 3.75 to 4.58; p<0.001). Dyssynergia was found in 72.9% at baseline and decreased to 14.4% at 1-year follow-up (p<0.001). Complaint reduction measured with the Proctoprom, significantly improved from baseline to 1-year follow-up (p<0.001). Quality of life (RAND-36) significantly improved in eight of nine domains at 1-year follow-up. No significant improvement was found in the domain vitality. In the PAF-trial, we demonstrated that PFPT yields a significant and clinical benefit in the time course and should be advocated as adjuvant conservative treatment in patients with chronic anal fissure. Discussion and recommendations Conservative treatment is the first step in patients with CAF. It includes dietary adaptations, the use of (extra) fibers and/or laxatives, toilet behaviour, lifestyle advice, ointment and PFPT. A selective approach is recommended based on the patient’s medical history and physical examination. We strive for a greater understanding and recognition of CAF leading to, at an early stage, a better outcome for the patient. Digital rectal examination including investigating of the pelvic floor muscles should be performed in routine clinical practice in the chronic phase, to distinguish between different causes of anorectal pain26 aiming to adequately refer patients for PFPT. To make the correct diagnosis and to reduce various treatment options, a local and/or regional partnership between a general practitioner (and collective) and a pelvic floor physical therapist is a desirable future perspective. The pelvic floor physical therapist as a practice assistant could be a possibility. But we also see a further development of 1.5-line care with the pelvic floor physical therapist in a one-off consultation in the role of consultant specialist as a renewed option to optimize the care for this anorectal disorder. In this thesis we have proven the effect of PFPT in patients with CAF and concomitant pelvic floor dysfunction. Pelvic floor physical therapists are trained to diagnose and treat a wide range of diagnoses related to pelvic floor dysfunctions. The personal contact and skills of the therapist are pivotal for the effect of conservative management in this debilitating disease. In addition, to optimize the outcome, it is essential to actively listen to the patient to identify patients concerns, to provide education about CAF and the use of ointment (when, how and why), to set realistic goals,27
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