Bridging the gap: pelvic floor physical therapy in the treatment of chronic anal fissure

Abstract

Anorectal disorders are common in general practice and the incidence of chronic anal fissure is 2.5 cases per 1000 persons in the Netherlands. 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. The classical symptom is pain during defecation, which may persist for hours, and has a significant impact on quality of life.

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.

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.

A digital rectal examination including examination of the pelvic floor muscles and a comprehensive evaluation of the pelvis and surrounding structures is important to determine the underlying cause of pain and pelvic floor dysfunction. 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. In the Pelvic floor Anal Fissure (PAF) study, we demonstrated that pelvic floor physical therapy yields a significant and clinical benefit in the time course and should be advocated as adjuvant conservative treatment in patients with CAF.