2 Results of a national survey among gastrointestinal surgeons 45 for not asking about pelvic floor complaints was a lack of knowledge about pelvic floor disorders.24 In our survey we did not inquire the reason for not asking for pelvic floor complaints, but this would be probably the same in gastrointestinal surgeons. We feel that knowledge about pelvic floor dysfunctions is beneficial in the treatment of anorectal disorders since this might result in a referral to another specialist in an early stage. The study shows that there is moderate consensus among the respondents concerning performing physical examination in patients with CAF. Only half of the respondents performed digital rectal examination and 37% never or almost never examined the pelvic floor muscles. Seniority in experience did not differentiate. In case of expecting a CAF, reason for not performing digital rectal examination could be the assumption that its contradicted or should be kept to a minimum because of associated pain. However, careful digital rectal examination is important to obtain information on anorectal anatomy and function.25,26 When identifying pelvic floor muscle dysfunction, patients can be appropriately referred to a pelvic floor physical therapist. Most of the respondents is accustomed to start with conservative measures, which is according to current guidelines.5,6,27-29 Diltiazem ointment was the preferred local treatment. Duration of application varies in studies and guidelines, but mostly a duration of at least 6 weeks is recommended.30-32 In our study 56% of the respondents indicated to prefer a duration of 6 weeks. Forty percent preferred a longer therapy duration, except for 4 respondents. Most respondents did have enough time to give instructions in the consulting room. This is important, since information about patient’ complaints, lifestyle advice, laxative- or ointment and its use require an explanation by the clinician.2,33 Pelvic floor dysfunctions can effectively be treated with pelvic floor physical therapy, but only 22% of the respondents referred to this treatment modality, a missed opportunity. The clinical effect of pelvic floor physical therapy in patient with CAF is investigated by the Pelvic floor Anal Fissure (PAF) study.34 Botulinum toxin injections were performed in the outpatient’s clinic by less than half of the respondents of whom 90% performed this without local anesthetics, excluding the 23 respondents who did not perform this procedure at all. More than half of the respondents (54%) performed botulinum toxin injections under general- or spinal anesthesia or sedation which is in accordance with a recent survey among members of the American Society of Colon and Rectal Surgeons (ASCRS).35 In current literature, there is no consensus on dose, site, or number of injections.29,36 This corresponds
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