Chapter 1 26 the sacrum, resulting in an increased distance between rectum and coccyx and opening of the anorectal angle. This can cause an increased pelvic floor muscle tone and stretch on the posterior sacrococcygeal ligament.69,70 Thus, a comprehensive evaluation of the chest, including respiratory function, abdomen, vertebral column, pelvis, and hips is important to determine the underlying cause of pelvic floor dysfunction.26,71 To exclude other pathology including abscess and/or fistula, endo-anal ultrasound can be used if that is possible and otherwise examination under anesthesia is indispensable. Conservative treatment Over the years, a broad spectrum of non-surgical options has been introduced aimed at alleviation of symptoms, achieving reduction of anal pressure, and ameliorating the healing process. Initial conservative management is comprised of lifestyle advice, fibre intake and/or use of laxatives and ointments. The use of fiber is effective in healing in acute fissures by using extra 20-25gr/d of fiber to normalise the defecation pattern and should be recommended to ensure avoidance and constipation.72,73 Improvement of toilet behaviour is important because of the anxiety of patients to go to the toilet in expectance of pain, and to prevent recurrence. Defecation could more easily be achieved by the squatting than by the sitting position. During the squatting position, a larger anorectal angle is achieved by relaxation of the pelvic floor muscles and less strain will be required for defecation.74 To make defecation easier, the legs could be raised by putting the feet on a small bench of 12-16 cm height75 and/or in a position bending forward in the “thinker” position.76 The “Thinker”by Rodin®
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