Danielle van Reijn-Baggen

BRIDGING THE GAP Pelvic floor physical therapy in the treatment of Chronic Anal Fissure Danielle A. van Reijn

Bridging the gap Pelvic floor physical therapy in the treatment of Chronic Anal Fissure Daniëlle A. van Reijn

Bridging the gap Pelvic floor physical therapy in the treatment of Chronic Anal Fissure Thesis, Leiden University ISBN: 978-94-6483-203-7 Cover art: Corry Ammerlaan-van Niekerk, www.artihove.nl Cover design: Mirella Boot Image parts: Proctos Kliniek, www.anatomytool.org, www.shutterstock.com, dr. S.S.C. Rao Medical College of Georgia, Augusta University Printed by: Ridderprint | www.ridderprint.nl This thesis is also available as an e-pub: The research presented in this thesis were conducted with financial support by the Proctos Kliniek and the Dutch Association for Pelvic Physiotherapy (NVFB). Additional financial support for printing of this thesis was kindly provided by Leiden University Medical Center, Novuqare, Stichting Bekkenbodem4All, Ceban HomeCare, Hoogland Medical BV, Medical4you BV, Pelvitec BV, ChipSoft, Coloplast BV, schwamedico Nederland BV, SOMT University of Physiotherapy, and the Scientific College Physical Therapy (WCF) of the Royal Dutch Society for Physical Therapy (KNGF). @ Daniëlle van Reijn, 2023, Leiden, The Netherlands. All rights reserved. No parts of this thesis may be reproduced, distributed, stored in a retrieval system, or transmitted in any form or by any means, without permission of the author or when appropriate, from the publishers of the publications.

Bridging the gap Pelvic floor physical therapy in the treatment of Chronic Anal Fissure Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Leiden, op gezag van rector magnificus prof.dr.ir. H. Bijl, volgens besluit van het college voor promoties te verdedigen op dinsdag 31 oktober 2023 klokke 16:15 uur door Daniëlle Adriëtte van Reijn geboren te Zwolle in 1968

Promotor: Co-promotores: Promotiecommissie: Prof. dr. R.C.M. Pelger Dr. I.J.M. Han-Geurts Dr. H.W. Elzevier Prof. dr. M.C. de Ruiter Prof. dr. M.E. Numans Prof. dr. E.C.J. Consten Dr. D.D.E. Zimmerman Proctos Kliniek, Bilthoven UMCG, Groningen, Meander Medisch Centrum, Amersfoort Elisabeth- TweeSteden Ziekenhuis, Tilburg

Voor mijn geliefden, Steven, Josephine, Emma, Pepijn, Olivier en Sebastiaan Mijn ouders Aad† en Toos

Contents Part I Chapter 1 General introduction 13 Chapter 2 Management of chronic anal fissure, results of a national survey among gastrointestinal surgeons in the Netherlands 39 International Journal of Colorectal disease 2022 Chapter 3 Pelvic floor physical therapy for pelvic floor hypertonicity: a systematic review of treatment efficacy 55 Sexual Medicine Reviews 2022 Chapter 4 To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high resolution anal manometry and transperineal ultrasound 93 International Journal of Colorectal disease 2023 Part II Chapter 5 Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-study): study protocol for a randomized controlled trial 123 Contemporary Clinical Trials Communications 2021 Chapter 6 Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial 145 Techniques in Coloproctology 2022 Reply to: Pelvic floor dysfunction and chronic anal fissure, a dog chasing its tail 167 Techniques in Coloproctology 2022 Chapter 7 Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF-trial): quality of life outcome 171 Techniques in Coloproctology 2023 Chapter 8 Pelvic floor physical therapy in patients with chronic anal fissure: long term follow-up of a randomized controlled trial 189 International Journal of Colorectal disease 2023

Part III Chapter 9 Summary of results and general discussion 213 Chapter 10 Dutch summary 227 Part IV Appendices List of abbreviations 242 List of publications 244 Dankwoord 246 Curriculum Vitae 249 Achtergrondinformatie cover 250

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.


CHAPTER 1 General introduction

Chapter 1 14 General introduction Chronic anal fissure (CAF) is a debilitating, painful anorectal condition associated with reduced quality of life.1,2 Searching for medical care is often deferred due to embarrassment.3 Prolonged persistence of symptoms and high recurrence rates indicate that present treatment modalities are not always sufficient. At present, there is a gap in treatment modalities between conservative management and surgery. This general introduction gains more knowledge on CAF, the relevant relationship between CAF and pelvic floor dysfunction, the current diagnostics and (conservative) management in patients with CAF. Definition, epidemiology, symptoms, anatomy, and pathophysiology Chronic anal fissure (CAF) is defined as a longitudinal tear in the anoderm with one or more signs of chronicity including hypertrophied anal papilla, sentinel pile and exposed internal sphincter muscle with symptoms present for longer than 4-6 weeks or recurrent fissures.4,5 The earliest known description dates from 1934 by Lockhart-Mummery.6 The classical symptom is pain during and immediately after defecation, caused by an injury of the multilayer squamous epithelium of the anoderm, which is richly innervated with pain fibers through the inferior rectal nerve. The pain can persist for hours and is often accompanied by bleeding.7,8 The majority of the fissures (80-90%) is located in the posterior midline. Approximately 10% of the fissures are affected in the anterior midline, mostly in female patients.9 It is theorized that the predisposition for the posterior midline has to do with the fact that specifically this area is poorly perfused.10 Fissures located off the midline position are considered atypical fissures and are more often associated with human immunodeficiency virus, syphilis, tuberculosis, herpes, leukaemia, Crohn’s disease, ulcerative colitis, and anal cancer.5

1 General introduction 15 CAF is one of the most common proctological problems. In a study by Mapel,11 in patients in the United States, the overall annual incidence was 0.11% (1.1 cases per 1000 persons). In the Netherlands, the incidence is 0.25% (2.5 cases per 1000 persons), with the highest incidence (4.3 per 1000) in women between 25-44 years.12 Anatomy of the anorectum The rectum comprises the most distal end of the gastrointestinal tract. It is a hollow tube, 12 to 15 cm long, composed of a layer of longitudinal muscle woven with the underlying circular muscle.13 The anal canal is defined as the beginning of the dentate line and ending of the anal verge, forming a transitional zone between the epithelium and perianal skin.14 The length of the anal canal is approximately 4 cm.15 At the dentate line, the columns of Morgagni begin with anal crypts at the base. The inner layer of the anal canal is composed of the internal anal sphincter (IAS), the outer layer of the anal canal consists of the external anal sphincter (EAS) and puborectalis muscle. In between these layers there is a fat containing intersphincteric space with the conjoined longitudinal muscle.16 The IAS ends about 1 cm proximal to the distal edge of the EAS and is a smooth muscle sphincter, innervated by the sympathic fibers from the inferior pelvic plexus and the parasympathic nerve fibers (S2-S4).16 The IAS is the main contributor to the anal resting pressure and contributes up to 80% of the anal resting pressure (50-70mmHg). Other contributors to anal resting pressure include the anal mucosal folds, the anal vascular cushions, the EAS and puborectalis muscle.17

Chapter 1 16 Another study by Penninckx et al.18 found that the estimated anal resting tone was generated by the nerve-induced activity in the IAS for 45%, myogenic tone for 10%, tonic activity of the EAS (30%) and anal haemorrhoidal plexus for 15%. The perineal body lies between the upper end of the anterior anal canal and the posterior wall of the urethral membrane. It serves as an intersection of the EAS, the bulbospongiosus muscle, the external urethral sphincter, and the levator ani muscle. The pelvic floor is a multifunctional complex of muscle fibers, fascia, ligaments, and connective tissue that form a hammock at the bottom of the abdomino-pelvic cavity. “Left inferior view of levator ani and external anal sphincter muscles -English labels” at AnatomyTOOL.org by Ron Slagter, LUMC and Marco DeRuiter, LUMC, license: Creative Commons Attribution-NonCommercial-ShareAlike The muscles of the pelvic floor consist of superficial muscles including the m. bulbospongiosus, m. ischiocavernosus, the perineal muscles and EAS. The deep pelvic floor muscles are the levator ani muscles composed of the puborectalis, pubococcygeus and iliococcygeus. These muscles are attached to the pubic bone, the ischial spine, and the arcus tendinous, a condensation of the obturator fascia in between these areas.17 The puborectalis muscle arises from the symphysis pubis and forms a loop around the recto-anal flexure.19 The puborectalis muscle acts together with the external anal and urethral sphincters to close the urinary and anal openings and contracts the sphincters rapidly in response to an increase of intra-abdominal pressure to prevent incontinence.16

1 General introduction 17 “Slagter - Drawing Inferior view of the male pelvic diaphragm 2 - English labels” at AnatomyTOOL. org by Ron Slagter, LUMC and Marco DeRuiter, LUMC, license: Creative Commons AttributionNonCommercial-ShareAlike At rest, the pelvic floor muscles remain in a state of continuous contraction (postural reflex) and the contractile traction of the puborectalis maintains the anorectal angle at approximately 900.20 This function creates a mechanical barrier for the flow of stool and maintenance of continence.21 Contraction of the puborectalis muscle displaces the anorectum anteriorly and changes the anorectal angle. The functions of the pelvic floor include anatomic support for the pelvic and abdominal organs, storage and voiding and the pelvic floor plays an important role in sexual function.22-25

Chapter 1 18 The levator ani together with the diaphragm, the deepest abdominal muscle, the transversus abdominus, generates and controls intra-abdominal pressure and contributes to lumbar spine stiffness.26,27 The pelvic floor is innervated by the branches of the sacral plexus S2, S3 and S4.19 “Anterior view of female pelvis; internal organs and innervation - Latin and English labels” at AnatomyTOOL.org by Ron Slagter, LUMC, Marco DeRuiter, LUMC and O. Paul Gobée, LUMC, license: Creative Commons Attribution-NonCommercial-ShareAlike

1 General introduction 19 Pathophysiology Although the etiology of CAF is uncertain, it is assumed that pain causes an increased sphincter pressure leading to diminished anodermal blood flow and local ischemia.9,10 Besides that, passing of hard stools or sudden evacuation of liquid stool can lead to mucosal damage, resulting in an overreaction of the external anal sphincter (EAS) continence reflex and an increase of basal resting pressure.28 This could lead to spasm which prevents CAF from healing.28,29 It is also theorized that insufficient stretchability of the anal sphincters leads to mucosal tears during defecation and this mucosa releases vasoconstrictors which arrests the healing process.30 Another hypothesis is that pelvic floor dysfunction may be part of the pathophysiology. In a retrospective study among 179 patients diagnosed with CAF, it was found that a large percentage of the patients had pelvic floor complaints such as obstructive defecation, sexual complaints, and pelvic floor dysfunction.31 Chronic constipation is also a predisposing factor.32

Chapter 1 20 Pelvic floor (dys)function and defecation Defecation is the term given for the act or process of expelling feces from the digestive tract via the anus.33 The integrity of the defecation and continence mechanism is a multifactorial process that involves somatic and visceral functions.34 Normal defecation requires anorectal synchronisation, an intact rectal sensation and perception, a contraction of the abdominal muscles and relaxation of the EAS and puborectalis muscle.20 During defecation, the voluntary effort of bearing down increases the intra-abdominal pressure, together with contraction of the rectum and the perineal muscles. To evacuate stool, the anal sphincters relax and the puborectalis muscle relaxes for straightening the anorectal angle.20 When the EAS and puborectalis muscle do not relax or even contract during attempted defecation this could result in an increase in the anorectal angle and hence prohibits the normal passage of stool.35 Preston,36 was the first describing the association of paradoxal anal contraction during attempted defecation and called the term ‘anismus’. The Rome-criteria advocated the term dyssynergic defecation.37 Dyssynergic defecation or dyssynergia is an acquired behavioral disorder and can be characterized by inadequate anal relaxation, paradoxical anal contraction, or inadequate rectal propulsive forces.38 Patients experience complaints of excessive straining, a feeling of incomplete evacuation, abdominal pain, abdominal discomfort, and anorectal pain.39,40 According to the ROME IV criteria, dyssynergia is established by 2 out of 3 anorectal function tests:

1 General introduction 21 first; abnormal anorectal evacuation pattern with manometry or electromyography, second; abnormal balloon expulsion test and third; impaired rectal evacuation by imaging (e.g. defecography).40 Anorectal pain could also result in increased tone (non-neurogenic hypertonicity) of the pelvic floor muscles, and this is typically associated with symptoms of postdefecatory pain which can last for hours.41,42 Levator ani syndrome is associated with tenderness to palpation on the levator ani muscle and increased anal resting pressures and there is an overlap between increased pelvic floor muscle tone and dyssynergia.37,40 This chronic anal pain resulting from tension or spasms in the levator muscles leads to compression of nerve endings and pain via peripheral sensitization.43 Myofascial pain is expressed in dysfunction in the muscle and surrounding connective tissues 44 and in the levator ani syndrome, the pain can radiate into the vagina, gluteal area or the thighs.43 Dyssynergia and/or increased tone of the pelvic floor may probably lead to a vicious circle of pain and be an underlying cause of delayed healing in patients with CAF.45 Impact on quality of life CAF is associated with reduced quality of life and can be influenced by physical, psychological, and social factors.1 Continuing complaints may lead to functional and psychosocial impairment.2 Patients with CAF show a high comorbidity of psychopathology, depression, and anxiety disorders with stress acting as a trigger and/or exacerbating factor.1 Symptomatic improvement with successful nonsurgical treatment, beneficially affects health-related quality of life.2 Diagnostics The diagnosis of CAF is based on medical history taking and a thorough physical exam should be performed to rule out other pathology. Before performing a digital rectal examination, it is important to explain the procedure to the patient and why, to diminish any fears and anxiety. Patients should be reassured that the digital examination will only last for a couple of minutes.46 During the assessment the patient lies on his/her left lateral position with the knees flexed at 900.. The examiner uses non-allergic gloves lubricated with water-based gel or vaseline.

Chapter 1 22 First, the anus and surrounding tissue is carefully inspected for skin excoriation, condyloma, skin tags, scars or external hemorrhoids, gaping anus, prolapsed hemorrhoids, or prolapse of the rectum and anal fissure. Chronic anal fissure could present as a wide and deep ulcer, sometimes with visible sphincter fibers, the presence of a sentinel polyp, keratinous edges, and hypertrophied anal papillae.47 The perineal sensation and anocutaneous reflexes are assessed by stroking the perianal skin in all four quadrants around the anus with a cotton bud. A normal response consists of a brisk contraction of the perianal skin, the anoderm, and the EAS. The anocutaneous reflex examines the integrity between the sensory nerves, S 2, S 3, S 4 neurons and motor innervation of the anal sphincter.46 A careful internal digital rectal examination combined with a vaginal examination is an another essential component of clinical investigation, to inquisite anal sphincter pressure, pelvic floor muscle tone- and function and dyssynergia.48-50 However, it should be mentioned that during medical school there is a lack of emphasis on the use of digital rectal examination and it is inadequately used, nor performed in clinical practice in patients with functional anorectal complaints.50 Besides that, the use of digital rectal examination is often delayed because of the assumption that it is contradicted or should be kept to a minimum because of associated pain. Starting digital rectal examination, the gloved finger should be placed in the center of the anus with the finger parallel to the skin of the perineum in the midline. It is important to wait for several seconds for the IAS to relax. Then slowly advance the lubricated finger into the anus. The resting pressure is predominantly attributed to the IAS. The sphincter pressure can be assessed in rest and scored as low, normal, or high. Any presence of tenderness, mass, stricture, stool, and its consistency should be noticed. The pelvic floor muscle tone is assessed (resistance provided by a muscle when a pressure/ deformation or a stretch is applied to it) on the levator ani muscle on both the right and left sides of the rectum and scored as decreased, normal or increased.48,49,51 Tenderness to palpation with traction on the puborectalis muscle is an important feature of levator ani syndrome.8,42 Tenderness can be scored according to each patients’ reactions: 0, no pain; 1, painful discomfort; 2, intense pain; with a maximum total score of 12.52 To investigate the function of the pelvic floor muscles, the patient is asked to squeeze the pelvic floor muscles as hard as possible (maximum strength), to sustain the squeeze contraction (30 seconds) (endurance), or to repeat squeeze contractions (repetitions). Measurement of squeeze pressure involves the exertion of pressure, compressing the assessor’s finger during digital palpation.52

1 General introduction 23 Digital rectal examination (Rao®) Next, the patient is asked to bear down (push). The examiner places his/her left hand on the patient’s abdomen and the patient is asked to push and bear down. Repeat this maneuver once or twice to make sure the patient understands the order and complied with the request, and that the responses are consistent.50 Push effort is scored as relaxation, indifferent or paradoxical contraction. To clinically diagnose dyssynergia, the presence of any two of the following findings can be used: the inability to contract the abdominal muscles, inability to relax the anal sphincter and puborectalis muscle, a paradoxal contraction of the anal sphincter and puborectalis muscle, or the absence of perineal descent.50 The sensitivity of digital rectal examination in diagnosing dyssynergia is 71% and the specificity is 76%.53 The current Rome criteria recommends the use of additional tests for diagnosing dyssynergia.54 Push effort (Rao®)

Chapter 1 24 When finishing the digital rectal exam, it is important to inspect the finger for obvious blood, mucus or pus and note the color of the feces. Gaping of the anal canal is suggestive of a neurological or sphincter defect.55 Surface electromyography (s-EMG) Pelvic floor muscle tone and function could also be measured with surface electromyography (s-EMG) (μV),49 with intravaginal or-anal probes.56,57 s-EMG is the only tool that can directly assess the pelvic floor muscle activity by measuring electrical signals which is generated along muscle fibers after depolarization of their motor nerve.58 s-EMG is used to evaluate motor control patterns, coordination and location of the pelvic floor muscles and gives the practioner and patient information about the ability to contract and relax and whether there is an increase or decrease in activity during a particular task.59 The use of down training, has been proven effective in creating awareness to avoid holding tension.57,60 A validated EMG electrode, the Multiple Array Probe (MAPLe®), was used in the present study. The MAPLe® probe uses a unipolar configuration, a validated location, is not sensitive for crosstalk and is capable of registering EMG-activity on all sides and depths of the pelvic floor during diagnosis and treatment.61 Biofeedback MAPLe®

1 General introduction 25 Anorectal manometry Anorectal high-resolution manometry (HRM) and three-dimensional high-definition manometry (3D-HRAM) are the ‘gold standard’ in investigating anorectal disorders.62 The International anorectal physiology working group (IAPWG) recommends anorectal manometry in the assessment of symptoms of functional anal pain for identification of anal sphincter hypertonicity and abnormalities of rectoanal coordination and parameters of evacuation.63 Manometry provides a comprehensive assessment of pressure activity in the rectum and sphincter complex with an assessment of rectal sensation, reflexes and rectal compliance.21 It can be used as a component of clinical evaluation for patients in whom advanced management strategies are regarded especially in disordered evacuation.64 In patients with CAF, anal manometry has demonstrated high anal basal pressures.65,66 Dyssynergia is defined by the absence of pressure reduction or an increase in the residual anal pressure during straining.67 Rao et al.68 classified 4 patterns: rectal pressure > 40 mmHg and paradoxical anal contraction (type I); rectal pressure < 40 mmHg and paradoxical anal contraction (type II); rectal pressure > 40 mmHg and incomplete anal relaxation (type III); and rectal pressure < 40 mmHg and incomplete anal relaxation (type IV). In a study of Jain,66 dyssynergic defecation was investigated with ARM and was more common in patients with CAF. 3D-HRAM resting pressure, squeezing, and straining Defecation not only involves correct anorectal synchronisation but also a correct thoraco-abdominoperineal dynamic and vertebral position.69 Alterations of pelvic statics may be a cause for dyssynergia. Lumbar hyperlordosis causes a horizontally position of

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®

1 General introduction 27 The use of ‘sitz baths’ is believed to help by improving hygiene and decreasing the IAS-tone mediated through sensory perianal skin receptors getting stimulated by warm water. The decrease in spasm and pain relief is attributed to this ‘thermosphincteric reflex’ through the activation of non-adrenergic and non-cholinergic neural release of nitric oxide.77,78 Gupta79 found a significant relief in anal burning and higher satisfaction score, but no significant pain relief and wound healing. It is advised to use the sitz bath only to cover the perineum and lower pelvis (with max.400C), and not whole baths because this could lead to vasodilatation and a decrease of circulation in the perineal area.80 Guideline recommendations differ on this subject. Sitz baths are recommended in international clinical guidelines,8,81 but not in the Dutch guideline.82 The use of ointments is aimed at reducing elevated sphincter tone and consequently increase the anodermal vascular blood flow, for which nitro-glycerine as well as calcium channel blockers may be prescribed.5,81 Topical glyceryl dinitrate, is a nitrogen donor that works by increasing nitric oxide, which induces relaxation of the IAS. Glycerine nitrate is better than placebo in healing CAF, however recurrence occurred in around 50% of those initially cured.7 Calcium channel blockers (diltiazem) achieve healing rates of 80.4%,83 but sideeffects e.g., mainly pruritis may occur. Recurrence of 60% was found in patients within 2 years after end of therapy.84 Both treatments have been shown effective although glyceryl nitrate has more side effects including headache.81 Botulinum toxin can be considered as an alternative or as a step-up approach when standard conservative therapy fails.81,82 Botulinum toxin is an exotoxin produced by the bacterium clostridium botulinum. Botulinum toxin blocks nerve conduction by preventing acetylcholine release from the presynaptic nerve endings resulting in temporary muscle paralysis and to improve local vascularity.85 Botulinum toxin is considered as a minimal invasive procedure with minor adverse effects which can be performed in an outpatient setting, however the recurrence rates vary between 1850%.7,86,87 Posterior tibial nerve stimulation Posterior tibial nerve stimulation is an office-based device to deliver retrograde electrostimulation to the sacral nerve. The tibial nerve is a mixed nerve containing L4–S3 fibers and originates from the same spinal segments as the innervations to

Chapter 1 28 the bladder and pelvic floor. The mechanisms of its effect are not fully elucidated, but stimulation of peripheral fibers transmits impulses to the sacral nerves and neuromodulates the lower urinary tract, rectum, and anal sphincters.88 It has been proven successful in the treatment of CAF, 89,90 although there is lack of related articles and data regarding this subject with methodological limitations. Posterior tibial nerve stimulation is not recommended in the Dutch guideline.82 Pelvic floor physical therapy Pelvic floor physical therapy (PFPT) is an important part of treatment of pelvic floor dysfunctions and includes strategies to optimize lumbopelvic and spinal function and to improve bowel, bladder, and sexual function.91,92 The aim of PFPT is to increase awareness and proprioception, to improve muscle relaxation and elasticity of the pelvic floor muscles, to restore abdominopelvic coordination, pelvic floor muscle function, rectal sensitivity and to reduce pain. 93,94 Interventions consist of education about pelvic floor musculature and related symptoms, behavioural modifications, exercises aimed at pelvic floor awareness and relaxation combined with soft-tissue manipulation and myofascial release.95-97 These pelvic floor soft-tissue techniques can be performed from external and internal in the pelvis. Dyssynergia and increased pelvic floor muscle tone can effectively be treated with PFPT including biofeedback therapy and/or electro galvanic stimulation,94,98-103 and are recommended in clinical guidelines.104,105 Biofeedback is a behavioral learning process that relies on operant conditioning; visual, auditory, or verbal feedback from instruments that measure anorectal activity.101 Several techniques can be used, solid-state manometry systems, surface electromyography, rectal balloons, and home devices. The aim is to improve muscle tone, voluntary contraction, and abdominopelvic coordination (abdominal push effort without excessive straining), to coordinate outward motion of the abdominal wall with relaxation of the pelvic floor and modulating rectal sensation.106 Manometry and rectal balloon training have the opportunity to display rectal and anal pressures, whereas surface electromyography provides information on the pelvic floor muscles.105 The feedback from the devices is used to identify the disordered function and used to guide the pelvic floor muscle exercises to learn how to transform and control the disordered function.101 Electro galvanic stimulation is used to improve muscle proprioception and relaxation of the pelvic floor muscles and is used as form of neuromodulation for pain relief.103,107-109

1 General introduction 29 Brown et al.110 found that patients are more likely to attend PFPT when referred on their initial consultation with the physician than those who were referred later. A multidisciplinary setting was associated with higher rates of PFPT attendance. Currently, PFPT is not recommended in the guidelines as a treatment option for CAF.8,81,82 Surgical options Although this thesis is only focused on the conservative management of CAF, various surgical procedures should be mentioned. Fissurectomy is the surgical procedure of choice in the Netherlands, followed by lateral internal sphincterotomy.111 Lateral internal sphincterotomy is the preferred treatment for refractory anal fissures and is still considered the golden standard because of superior healing rates,81,82 although fecal incontinence is a potential risk.7,86,112-114 In this regard, the development of new treatment possibilities having the same or better outcome but with less side effects remains an actual assignment. Pelvic floor physical therapy could bridge the gap between conservative management and surgery.

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