Outline of the thesis This thesis is divided in four parts. In part I, chapter 1, the general introduction, we described the definition, symptoms, epidemiology, and pathophysiology of chronic anal fissure including an overview of relevant anatomy of the anorectum and pelvic floor musculature. We further outlined the current diagnostics, the relevant relationship between chronic anal fissure and pelvic floor dysfunction, and management of chronic anal fissure. Chapter 2 presents the results of a national survey on management of chronic anal fissure among gastrointestinal surgeons in the Netherlands. Chapter 3 reveals the results of a systematic review on the treatment efficacy of pelvic floor physical therapy for increased pelvic floor muscle tone. Chapter 4 outlines the results of a study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry and transperineal ultrasound. Part II, consist of four chapters focussing on the efficacy of treatment of pelvic floor physical therapy in patients with chronic anal fissure and pelvic floor dysfunction. In Chapter 5 we described the study protocol of a randomized controlled trial, the Pelvic floor Anal Fissure (PAF)-study. Chapter 6 presents the results of the PAFstudy from pre-to posttreatment at 8-and 20-week follow-up and the response from a letter to the editor to our manuscript. The results from the PAF-study on quality of life are presented in chapter 7. Chapter 8 outlines the results of the PAF-study at 1-year follow-up. Part III, chapter 9 contains the summary and implications of this thesis on future practice. In Chapter 10, the summaries of the studies are reported in Dutch.
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