Current care for proctological complaints and pelvic floor physical therapy in a one-time consultation: a national survey among general practioners, surgeons, gastroenterologists and pelvic floor physical therapists

Current care for proctological complaints and pelvic floor physical therapy in a one-time consultation: a national survey among general practioners, surgeons, gastroenterologists and pelvic floor physical therapists | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Current care for proctological complaints and pelvic floor physical therapy in a one-time consultation: a national survey among general practioners, surgeons, gastroenterologists and pelvic floor physical therapists Danielle A. Reijn-Baggen, Ingrid. J. Han-Geurts, Henk W. Elzevier, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6826199/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Proctological complaints are very common and can significantly impair quality of life. It is not known how these problems are currently treated by general practioners (GPs). While most cases improve with conservative treatment, some persist or recur and require specialist referral. GPs rarely assess pelvic floor dysfunction, despite its potential contribution to recurring symptoms. A one-time consultation with a pelvic floor physical therapist could help to close this gap and improve care efficiency. Objectives The study aimed to evaluate current GP practices in managing proctological complaints, such as hemorrhoids, chronic anal fissure and fecal incontinence. Additionally, this study assessed the willingness of healthcare professionals to implement a one-time pelvic floor physical therapist consultation. Methods GPs completed a questionnaire on diagnostic approaches, treatment and referral habits. Gastrointestinal surgeons, gastroenterologists, pelvic floor physical therapists, and GPs were also surveyed about their attitudes toward introducing a pelvic floor physical therapist consultation. Results Responses were received from 73 GPs, 27 surgeons, 6 gastroenterologists, and 56 pelvic floor physical therapists. GPs asked about urological problems in 36% and sexual complaints in only 7% of cases. Digital rectal examination was done by 47% of GPs, but only 3% assessed the pelvic floor muscles. Over 59% of GPs advised on lifestyle and toilet behaviour. In the past year, 47% referred 10–25% of patients to a specialist. Support for a one-time pelvic floor physical therapist consultation was high among GPs (82%), surgeons (82%), gastroenterologists (66%), pelvic floor physical therapist (88%). Key reasons included time constraints, knowledge gaps, improved care, and cost-effectiveness. Conclusions Dutch GP-guidelines are generally followed. There is strong support for integrating a one-time pelvic floor physical therapist consultation into the care pathway for proctological complaints. Figures Figure 1 Figure 2 Introduction Anorectal disorders e.g. proctological complaints, are common in general practice with an incidence of chronic anal fissure of 3.8, and fecal incontinence (FI) of 0.9 per 1000 patient years. The prevalence of hemorrhoids is nearly 13.3 per 1000 in the Dutch population. 1 These amounts are probably underreported due to embarrassment in searching for medical care. 2 Anorectal complaints can consist of pain during and/or after defecation, loss of blood, itching, swelling, soiling and loss of fecal material. Continuing complaints may lead to functional and psychosocial impairment, which have a large impact on quality of life. 3 , 4 The cause of these problems can mostly be treated by conservative measures like lifestyle advice, fibre intake and/or the use of laxatives. 5 Despite these measures, a percentage tend to recur or persist, and patients are then referred to a specialist for further evaluation or surgery. Numbers of referral are however unknown. Pelvic floor dysfunction e.g. dyssynergia and increased- or decreased pelvic floor muscle tone and -function, may underlie proctological complaints and a reason for unresponsiveness to treatment. Dyssynergia is an acquired behavioral disorder and can be characterized by inadequate anal relaxation, paradoxical anal contraction, or inadequate rectal propulsive forces. 6 This could lead to prolonged straining, frequent attempts of evacuation, a feeling of incomplete evacuation and anorectal pain because of incomplete relaxation of the puborectalis muscle. 7 , 8 FI is also associated with pelvic floor dysfunction and increases with age. 9 Due to their complexity and varied presentation, pelvic floor dysfunctions are frequently overlooked and insufficiently diagnosed in clinical practice. 10 , 11 Besides that, in the Dutch guidelines 12 , 13 , pelvic floor physical therapy is not mentioned as a treatment option for patients with common proctological complaints. A selective approach is recommended based on the patient’s medical history and physical examination. A comprehensive careful digital rectal examination is an important topic to obtain information on anorectal anatomy and function. 8 However, with increasing demand for care, this means that there could be a shortage in time and knowledge in general practice to conduct extensive research into the (dys)functions of the pelvic floor. A one-time consultation with a pelvic floor physical therapist (PFPT) after consultation of the general practitioner (GP) could optimize proctological care. If patients have an underlying pelvic floor dysfunction they can be referred to a PFPT for treatment which has proven effective in patients with chronic anal fissure 14 , 15 and other anorectal dysfunctions. 16 When there is no underlying pelvic floor dysfunction patients can be adequately be referred for additional diagnostic workup or surgery. This renewed working method could contribute to the current quality of care, prevention of complaints and cost reduction. Whether GPs, gastrointestinal surgeons, gastroenterologists and PFPTs are willing to take part in this renewed option for care, is unknown. Hence, the aim of the present study is to investigate the current care for common proctological and concomitant pelvic floor complaints and the willingness of health care professionals to implement a one-time consultation of a PFPT in current healthcare system. Methods We conducted a cross-sectional questionnaire study between January 2025 and May 2025, in collaboration with the Department of Public Health & Primary Care of the Leiden University Medical Center and the Proctos Clinic in the Netherlands. This survey study was performed and reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). 17 The survey for this study was constructed in a multidisciplinary team comprising a GP, a surgeon, an epidemiologist and a PFPT. The survey was written in Dutch, and data were collected using a web-based program called Survio. 18 The survey was sent by email and by social media to GPs. PFPTs received a link through a newsletter of the national society of PFPTs (NVFB). Gastroenterologists and gastrointestinal surgeons were invited through the professional associations and by social media with a link to the survey. The survey for GPs consisted of 26 questions concerning demographics, incidence of new patients a year with proctological complaints, investigation and treatment of patients with anal fissures, hemorrhoids and FI, and the willingness to implement a one-time consultation by a PFPT. (Appendix 1.) The survey for gastrointestinal surgeons, gastroenterologists (Appendix 2.) consisted of 10 questions concerning demographics and willingness to implement this renewed option of care. Additionally, the survey of PFPTs consisted of 15 questions. (Appendix 3.) The survey was accompanied by a short introduction explaining the objectives of the study and length of time of the survey (< 10 min). No time limit was set for filling in the survey. The survey was available online from January 30 th 2025 to 1 th May 2025. The questionnaire has not been published elsewhere. Statistical analysis Descriptive characteristics are reported for respondents’ demographics, the incidence of proctological problems e.g. hemorrhoids, (chronic) anal fissure and FI, history taken concerning other pelvic floor complaints, physical examination, treatment and referral. Medians and interquartile ranges are reported for non-normally distributed data and means and standard deviations for normally distributed data. Categorical variables are presented as percentages and compared with the Chi-square test if appropriate. Survio 18 automatically collected all data after which the data were exported to a Microsoft Excel spreadsheet and then imported to SPSS (version 28.0). To prevent missing data, all questions were mandatory with automated skip logic. Results In total, 73 GPs and GP residents filled in the questionnaire completely, 70% female, and 33% of the GPs had experience of more than fifteen years. Respondents’ characteristics are shown in table 1. The mean of patients per practice was 3,580 (range 0,0-13,000). The most common proctological complaint seen by GPs where hemorrhoids (62% of the GPs saw 10-30 new patients per year), followed by anal fissure (25%) and FI (6%). 27 gastrointestinal surgeons, 6 gastroenterologists and 56 PFPT’s filled in the questionnaire. Most surgeons (59%) had 5-15 years of experience, while 50% of gastroenterologist (50%) and 73% of PFPTs had more than 15 years of experience. (Table 1) Medical history and physical examination Among GP respondents, 12% never or almost never inquired about urological complaints, (e.g. frequency, urgency, urine-incontinence), while 36% did so regularly or always. Only 7% routinely asked about coexisting sexual complaints. Overall, 78% of GPs almost always or always performed an inspection of the anus and 47% performed a digital rectal examination. Only 3% of the respondents indicated that they performed physical examination of the pelvic floor muscles during digital rectal examination while 30% never or almost never did. Eight percent almost always or always asked the patient how to push or bear down, while 55% never or rarely addressed this (Figure 1.) Treatment Over 80% of GPs consistently discussed toilet behavior and provided lifestyle advice to patients with anal fissures and hemorrhoids, compared to 59% for those with FI. (Table 2.) Hemorrhoids Sixty-seven percent of the responders prescribes macrogol vs psylliumfibers (40%) in more than half of the cases. Twelve percent of the respondents referred to a PFPT in more than half of the cases for this complaint, while 26% almost never or never did. Fourteen percent of the GPs referred patients to a hospital for further treatment in at least half of the cases. Fissures For patients with acute anal fissures, macrogol was the prescribed laxative (71%), while psylliumfibers were prescribed in 29 % in more than half of the cases. In acute anal fissures, 30% of the responders always or almost prescribed lidocaine and Diltiazem (25%) of the cases. In case of chronic anal fissures, 70% of GPs prescribes macrogol in more than half of the cases, compared to 37% who prescribed psylliumfibers. Diltiazem was the preferred ointment for 68% of the respondents in more than half of the cases. In at least half of the cases, 33% of GPs referred patients with chronic anal fissures to a general hospital. Fecal incontinence (FI) Forty-four percent prescribes psylliumfibers in more than half of the cases, compared to 16% who prescribed macrogol. Sixty-three percent referred patients to PFPT, and 51% to a hospital for FI in more than half of the cases. For all kinds of proctological complaints, 85% of respondents preferred referring a patient to a surgeon, compared to 26% who opted for a gastroenterologist in more than half of the cases. Implementation one-time consultation Eighty-two percent of GPs expressed willingness to explore the implementation of a one-time consultation by a PFPT, whereas only 3% were opposed to the idea. Reasons for implementing is too little time in the consulting room, (63% agreed), too little knowledge concerning proctological complaints (55% agreed) and 78% of the respondents’ notices that they fail in performing a pelvic floor investigation. (Figure 2) Over 85% agreed that a one-time consultation would contribute to optimal care. Additionally, 36% believed it would create more time during consultations, 46% expected cost reduction, and 49% anticipated shorter waiting times for hospital referrals. A large percentage of respondents from GPs (83%) want to start with a consultation of PFPT including therapy. Reasons for not implementing a one-time consultation included concerns about missing an underlying pathology (mentioned by five respondents) and a preference to manage the complaints themselves (mentioned by three respondents). Surgeons 27 surgeons filled in the survey, 63% men. 44 % is colorectal surgeon, 59 % GE-surgeon and 11% residents. Eighty-two percent of the surgeons are willing to investigate a one-time consultation with a PFPT, while only 3% did not. Main reasons for implementing include insufficient qualification to perform pelvic floor assessments (reported by over 50% of respondents), limited consultation time (59%), time saving in current practice (70%), the potential for optimal care (82%), and cost reduction (63%). The reasons cited for not implementing this approach were concern about missing underlying pathologies and perceived insufficient expertise of PFPTs, each mentioned by two respondents. Pelvic floor physical therapists Fifty-six PFPTs filled in the survey. Hundred percent women of whom 73% had at least 10 years of experience as PFPT. Fifty seven percent of the respondents treated 10-30 patients per year with hemorrhoids, chronic anal fissure (43%) and FI (38%). Eighty-eight percent is willing to implement a one-time consultation. An important reason to implement is quality of care for (91% agreed), this is my expertise (88% agreed), right care at the right place (82% agreed). Reasons not to implement is for two PFPTs, too little time and waiting list. Gastroenterologists Only six gastroenterologists filled in the questionnaire. Sixty-seven of them are willing to implement a one-time consultation. Main reason to implement is cost reduction, less time in the consulting room and quality of care. Discussion Implementation of Dutch guidelines 12,13 for GPs are generally followed. GPs see more patients with hemorrhoids per year compared to chronic anal fissure and fecal incontinence (FI). Besides a higher incidence of hemorrhoids, another reason could be that patients are more willing to go to a GP with complaints of loss of blood and swelling because they are more concerned about other underlying diseases. In contrary, anal pain or FI are probably more surrounded by shame, patients are too embarrassed to talk about and it is less asked for by a primary care providers. 19 Asking for urological complaints in patients with proctological complaints was more common than asking for sexual problems. Although there is a strong relationship between sexual and /or physical abuse history in gastrointestinal disorders and pelvic floor disfunction 20,21 , only few GPs always or almost always ask for sexual complaints although it is recommended in the Dutch guideline for GPs. 13 A history of sexual and/or physical abuse may play a role in the divergence between the symptoms patients report and objective measurements and may alter treatment recommendations. 22 and is therefore an important topic of history taken. A large percentage of GPs start with advices concerning lifestyle, toiletbehaviour and the use of fibers, which is in accordance to current guidelines. 12,13 This is an important finding of our study, because it is known that fiber intake of at least 25-35 grams per day will stabilize symptoms and diminish the risk of bleeding in patients with hemorrhoids with 50%. 23 In patients with acute fissure, the use of fiber is effective in healing and should be recommended to ensure avoidance and constipation. 24,25 Although the requirement of daily fiber intake is around 35 to 40 g/d, the average diet contains less (12-18 g/d) and therefore a recommendation to use extra psylliumfibers should be kept in mind. 26 Research on the effect of psylliumfibers was found in a randomized study by Bliss 27 in 189 patients with FI. FI severity (calculated using number of FI episodes, consistency and amount of stool) was significantly better in the psyllium group. In our study, the advice of using psylliumfibers versus electrolytes was almost equal in half of the cases in patients with FI. A study of Bharucha 28 investigated bowel patterns, rectal urgency, and daily routine influenced the occurrence of FI. Stool characteristics explained 46% of the likelihood for incontinence episodes. Lifestyle adjustments and advice among toiletbehaviour are recommended in the European Guideline for FI. 29 although 27% of the GP respondents in our study gives these advices in less than half of the cases in patients with FI. The most prescribed ointment was diltiazem in more than 50% of the cases. This is according to current guidelines. 30 Remarkably, the recommendation how to use the ointment differs between acute and chronic anal fissures in the current Dutch guideline. 13 It advises to insert the ointment into the anus for acute anal fissures and before defecation, in contrast with chronic anal fissures, apply it around the anus. The reason to use diltiazem is that calcium channel blockers relax the internal sphincter by blocking calcium influx to the cytoplasm of smooth muscle cells. 31 Therefore, it should be inserted into the anus, in chronic- as well as in acute anal fissures. A correct application of the ointment (internally) is of crucial importance in case of relaxation and healing of the fissure. The Dutch guideline recommends performing digital rectal examination in patients with proctological complaints such as chronic anal fissures and hemorrhoids but only 47% of the GPs almost always or always perform this. In our study shows there is moderate consensus among the respondents concerning performing investigation of the pelvic floor muscles in patients with proctological complaints. Only 3% of the GPs always or almost always examined the pelvic floor muscles. This is even less than what was found in a recent survey on management of chronic anal fissure among gastrointestinal surgeons in the Netherlands, in which 37% of the respondents never or almost never examined the pelvic floor muscles. 32 Digital rectal examination including pelvic floor muscle investigation is needed to distinguish between different causes of proctological complaints. 33 Only three percent of the respondents almost always or always referred patients to PFPT. It is important to consider the systematic review by Kalkdijk et al. 34 which found that among patients with hemorrhoids, all reported straining during defecation prior to the onset of hemorrhoidal symptoms. Also, dyssynergic defecation was significantly more frequent in patients with hemorrhoids compared to healthy subjects. Treatment of underlying pelvic floor dysfunction e.g. dyssynergic defecation could be an important step to take and this could be more effective than treating hemorrhoids with surgery only. 34 Besides that, surgery could even be harmful by damaging the mucosal tissue which could result in soiling and pain. 35 In our study it was found that between 14-50% of the respondents patients were referred to a specialist depending on the diagnose, in more than half of the cases. In case of referral, we found that GPs, preferred a surgeon for proctological complaints. In a recent survey in Italy among residents and young specialists was found that 75% of the respondents had to deal for the first time with proctological problems early on during their postgraduate training and a minority could practice proctology for a prolonged and continued period. 36 This could influence their skills of performing surgery and therefore the outcome of treatment and higher risk of recurrence when there is an underlying pelvic floor dysfunction. If this is the same for Dutch surgeons is not investigated. GPs express their willingness to implement a one-time consultation for patients with common proctological complaints. Key motivations include time savings during consultations, limited knowledge regarding proctological conditions, the pursuit of optimal care, and potential cost reduction. In addition, surgeons, gastroenterologists and PFPTs are also positive concerning the implementation of a one-time consultation. Dutch PFPTs have the knowledge, skills and are trained to diagnose and treat a wide range of diagnosis related to pelvic floor dysfunctions. PFPTs have the time for history taking and to actively listen to the patients and provide education about complaints. 37 In current Dutch healthcare system, PFPT is not systematically integrated into the care pathway, and there is no structural reimbursement. Moreover, patients without supplementary insurance are required to pay for a consultation. PFPTs could fill the gap between the GP and the specialist. Future studies are needed to assess whether a one-time consultation will lead to more focused treatment and efficiency and prevention of complaints. Strengths and limitations A strength of this study is that participating GPs had a broad range of experience and have their practices in different parts of the Netherlands, in both cities and rural areas, which is probably a representative sample. However, we cannot extrapolate the answers of the Dutch GPs to other countries. Questions directed to the management of proctological complaints reflect their current practice and gives a clear inside the usual care but could have an influence on desirable answers. The number of patients with different proctological complaints was an estimation and not objectively measured by routine data or registration, this may have caused response-bias. The response rate of the gastro-intestinal surgeons and gastroenterologists was low; this may have caused non-response bias. Besides that, the questionnaire was sent with a link on a newsletter to members of the Dutch Coloproctology Working group that consist of members that have a large experience and affiliation in treating anorectal complaints, which could have caused selection bias. Conclusion This research offers valuable insights in how Dutch GPs investigate, treat and refer patients with proctological complaints. Pelvic floor dysfunction is not consistently assessed and examined, and underlying pathophysiology could therefore be missed. GPs, PFPTs, gastrointestinal surgeons and gastroenterologist are positive concerning the implementation of a one-time consultation with a PFPT for common proctological complaints. Further research is needed to investigate the effect of the implementation of a one-time consultation of a PFPT in daily practice on quality of care, efficacy and efficiency of treatment of benign proctological complaints. Abbreviations GP General Practioner PFPT Pelvic Floor Physical Therapist FI Fecal Incontinence Declarations Ethics approval and consent to participate The Medical Ethical Committee of Leiden University Medical Center confirmed that formal ethical approval was not necessary under Dutch Law. This study does not involve human participants, human data, or human tissue. Therefore, the Declaration of Helsinki does not apply. As ethics approval was not required for this minimal-risk study, informed consent was implied through voluntary completion of the survey. Participants were presented with an information statement outlining the study purpose, procedures, and data confidentiality before proceeding. Consent for publication Not applicable Availability of data and materials Data may be made available through formal data sharing agreement with the corresponding author ( [email protected] ) on reasonable request. Competing interests The authors declare no competing interests. Funding No external funding was obtained for the execution of this study. Acknowledgements The authors thank all participating general practioners, surgeons, gastroenterologists and pelvic floor physical therapists for completing the questionnaire. References Nivel. Jaarcijfers aandoeningen-Huisartsenregistraties. 2023;( .). Gilani A, Tierney G. Chronic anal fissure in adults. 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Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex. Med Hypotheses Sep. 2016;94:25–9. 10.1016/j.mehy.2016.06.005 . Manzo CA, Annicchiarico A, Valiyeva S, et al. Practice of proctology among general surgery residents and young specialists in Italy: a snapshot survey. Updates Surg Sep. 2023;75(6):1597–605. 10.1007/s13304-023-01540-5 . Aziz I, Whitehead WE, Palsson OS, Tornblom H, Simren M. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol Jan. 2020;14(1):39–46. 10.1080/17474124.2020.1708718 . Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Appendix2V1.docx Appendix3V1.docx Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Apr, 2026 Reviews received at journal 26 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviewers agreed at journal 28 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviews received at journal 24 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviews received at journal 05 Aug, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers invited by journal 21 Jul, 2025 Editor assigned by journal 16 Jun, 2025 Submission checks completed at journal 16 Jun, 2025 First submitted to journal 16 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Reijn-Baggen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIie3RMQrCMBSA4RcK6RI7p6B4hUAHHTxMewPFxaFgQGg35wriDRxcOkcK7dIDODjEpXO7OIopBcElZBTMPz1CPhJ4ADbbLyY+E+IMNvNhluakpsMcmpFeJQbEE450SHyHWbrj69WJRudUYKkjvsDMIWUD4/rKg0NOo7wOXaYjTABDGS6A0ogHo57cAFM9cVuUvRSZPhQ5GhHCoEv6V5Ai3ID4BVmKbq8IUR8jJQ3yOkq0xKvSiwyfirhVE5B4McmroqSthoAzrGbLATAbjhDXgW8tja/abDbbX/UGi3dLb2tjhHcAAAAASUVORK5CYII=","orcid":"","institution":"Leiden University Medical Centre","correspondingAuthor":true,"prefix":"","firstName":"Danielle","middleName":"A.","lastName":"Reijn-Baggen","suffix":""},{"id":490199818,"identity":"4c1f2a6e-f9f8-4898-b70a-8e6e8e5b1576","order_by":1,"name":"Ingrid. J. Han-Geurts","email":"","orcid":"","institution":"Proctos Clinic","correspondingAuthor":false,"prefix":"","firstName":"Ingrid.","middleName":"J.","lastName":"Han-Geurts","suffix":""},{"id":490199819,"identity":"1be85077-7bde-4eb9-9424-9230197fec3e","order_by":2,"name":"Henk W. Elzevier","email":"","orcid":"","institution":"Leiden University Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Henk","middleName":"W.","lastName":"Elzevier","suffix":""},{"id":490199820,"identity":"05386045-29c5-4326-a89c-cbc0cc3bbef5","order_by":3,"name":"Tobias N. Bonten","email":"","orcid":"","institution":"Leiden University Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"N.","lastName":"Bonten","suffix":""}],"badges":[],"createdAt":"2025-06-05 07:08:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6826199/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6826199/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87714502,"identity":"679f4af0-ab0f-4083-9162-fbe5e1bd0cb6","added_by":"auto","created_at":"2025-07-28 09:02:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34390,"visible":true,"origin":"","legend":"\u003cp\u003ePhysical examination by General Practioner\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/1c33330bda293b63510ee34c.jpg"},{"id":87714503,"identity":"81e6e6aa-0d85-4250-8000-fc4175e5c523","added_by":"auto","created_at":"2025-07-28 09:02:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22471,"visible":true,"origin":"","legend":"\u003cp\u003eImplementation one-time consultation pelvic floor physical therapist\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/f4abe93e7f11bb7404520990.jpg"},{"id":87717111,"identity":"90e4ec05-657e-48ed-9d18-4d046a748915","added_by":"auto","created_at":"2025-07-28 09:18:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":601361,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/77904341-855c-4fdf-ac94-410791fe3fa5.pdf"},{"id":87714504,"identity":"23e0c970-192e-4019-9a61-aaaccedf49e8","added_by":"auto","created_at":"2025-07-28 09:02:04","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":32879,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/4685e29dcd6ac71fd4817eef.docx"},{"id":87714508,"identity":"dc724d3e-f6b7-4167-8f29-e55b45f9189f","added_by":"auto","created_at":"2025-07-28 09:02:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23177,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2V1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/b6eb50d0acbe37c709d89f63.docx"},{"id":87716137,"identity":"2761ccae-24b8-4cbf-b93a-bf913445867a","added_by":"auto","created_at":"2025-07-28 09:10:05","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22535,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3V1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/fc5585987dda2864c342d5e8.docx"},{"id":87714505,"identity":"896bc340-fc0f-43a3-b5a6-4ab2bff91d40","added_by":"auto","created_at":"2025-07-28 09:02:04","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":21943,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6826199/v1/1b76aa0324e1f03e46271264.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Current care for proctological complaints and pelvic floor physical therapy in a one-time consultation: a national survey among general practioners, surgeons, gastroenterologists and pelvic floor physical therapists","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnorectal disorders e.g. proctological complaints, are common in general practice with an incidence of chronic anal fissure of 3.8, and fecal incontinence (FI) of 0.9 per 1000 patient years. The prevalence of hemorrhoids is nearly 13.3 per 1000 in the Dutch population.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e These amounts are probably underreported due to embarrassment in searching for medical care.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Anorectal complaints can consist of pain during and/or after defecation, loss of blood, itching, swelling, soiling and loss of fecal material. Continuing complaints may lead to functional and psychosocial impairment, which have a large impact on quality of life. \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe cause of these problems can mostly be treated by conservative measures like lifestyle advice, fibre intake and/or the use of laxatives. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Despite these measures, a percentage tend to recur or persist, and patients are then referred to a specialist for further evaluation or surgery. Numbers of referral are however unknown.\u003c/p\u003e\u003cp\u003ePelvic floor dysfunction e.g. dyssynergia and increased- or decreased pelvic floor muscle tone and -function, may underlie proctological complaints and a reason for unresponsiveness to treatment. Dyssynergia is an acquired behavioral disorder and can be characterized by inadequate anal relaxation, paradoxical anal contraction, or inadequate rectal propulsive forces.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This could lead to prolonged straining, frequent attempts of evacuation, a feeling of incomplete evacuation and anorectal pain because of incomplete relaxation of the puborectalis muscle.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e FI is also associated with pelvic floor dysfunction and increases with age.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Due to their complexity and varied presentation, pelvic floor dysfunctions are frequently overlooked and insufficiently diagnosed in clinical practice.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Besides that, in the Dutch guidelines\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, pelvic floor physical therapy is not mentioned as a treatment option for patients with common proctological complaints.\u003c/p\u003e\u003cp\u003eA selective approach is recommended based on the patient\u0026rsquo;s medical history and physical examination. A comprehensive careful digital rectal examination is an important topic to obtain information on anorectal anatomy and function. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, with increasing demand for care, this means that there could be a shortage in time and knowledge in general practice to conduct extensive research into the (dys)functions of the pelvic floor.\u003c/p\u003e\u003cp\u003eA one-time consultation with a pelvic floor physical therapist (PFPT) after consultation of the general practitioner (GP) could optimize proctological care. If patients have an underlying pelvic floor dysfunction they can be referred to a PFPT for treatment which has proven effective in patients with chronic anal fissure\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and other anorectal dysfunctions.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e When there is no underlying pelvic floor dysfunction patients can be adequately be referred for additional diagnostic workup or surgery.\u003c/p\u003e\u003cp\u003eThis renewed working method could contribute to the current quality of care, prevention of complaints and cost reduction. Whether GPs, gastrointestinal surgeons, gastroenterologists and PFPTs are willing to take part in this renewed option for care, is unknown.\u003c/p\u003e\u003cp\u003eHence, the aim of the present study is to investigate the current care for common proctological and concomitant pelvic floor complaints and the willingness of health care professionals to implement a one-time consultation of a PFPT in current healthcare system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a cross-sectional questionnaire study between January 2025 and May 2025, in collaboration with the Department of Public Health \u0026amp; Primary Care of the Leiden University Medical Center and the Proctos Clinic in the Netherlands.\u003c/p\u003e\u003cp\u003eThis survey study was performed and reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The survey for this study was constructed in a multidisciplinary team comprising a GP, a surgeon, an epidemiologist and a PFPT. The survey was written in Dutch, and data were collected using a web-based program called Survio. \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe survey was sent by email and by social media to GPs. PFPTs received a link through a newsletter of the national society of PFPTs (NVFB). Gastroenterologists and gastrointestinal surgeons were invited through the professional associations and by social media with a link to the survey.\u003c/p\u003e\u003cp\u003eThe survey for GPs consisted of 26 questions concerning demographics, incidence of new patients a year with proctological complaints, investigation and treatment of patients with anal fissures, hemorrhoids and FI, and the willingness to implement a one-time consultation by a PFPT. (Appendix 1.) The survey for gastrointestinal surgeons, gastroenterologists (Appendix 2.) consisted of 10 questions concerning demographics and willingness to implement this renewed option of care. Additionally, the survey of PFPTs consisted of 15 questions. (Appendix 3.) The survey was accompanied by a short introduction explaining the objectives of the study and length of time of the survey (\u0026lt;\u0026thinsp;10 min). No time limit was set for filling in the survey. The survey was available online from January 30 th 2025 to 1 th May 2025. The questionnaire has not been published elsewhere.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive characteristics are reported for respondents\u0026rsquo; demographics, the incidence of proctological problems e.g. hemorrhoids, (chronic) anal fissure and FI, history taken concerning other pelvic floor complaints, physical examination, treatment and referral. Medians and interquartile ranges are reported for non-normally distributed data and means and standard deviations for normally distributed data. Categorical variables are presented as percentages and compared with the Chi-square test if appropriate.\u003c/p\u003e\u003cp\u003eSurvio\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e automatically collected all data after which the data were exported to a Microsoft Excel spreadsheet and then imported to SPSS (version 28.0). To prevent missing data, all questions were mandatory with automated skip logic.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 73 GPs and GP residents filled in the questionnaire completely, 70% female, and 33% of the GPs had experience of more than fifteen years. Respondents\u0026rsquo; characteristics are shown in table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean of patients per practice was 3,580 (range 0,0-13,000). The most common proctological complaint seen by GPs where hemorrhoids (62% of the GPs saw 10-30 new patients per year), followed by anal fissure (25%) and FI (6%).\u003c/p\u003e\n\u003cp\u003e27 gastrointestinal surgeons, 6 gastroenterologists and 56 PFPT\u0026rsquo;s filled in the questionnaire. Most surgeons (59%) had 5-15 years of experience, while 50% of gastroenterologist (50%) and 73% of PFPTs had more than 15 years of experience. (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMedical history and physical examination\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong GP respondents, 12% never or almost never inquired about urological complaints, (e.g. frequency, urgency, urine-incontinence), while 36% did so regularly or always. Only 7% routinely asked about coexisting sexual complaints.\u003c/p\u003e\n\u003cp\u003eOverall, 78% of GPs almost always or always performed an inspection of the anus and 47% performed a digital rectal examination. Only 3% of the respondents indicated that they performed physical examination of the pelvic floor muscles during digital rectal examination while 30% never or almost never did. Eight percent almost always or always asked the patient how to push or bear down, while 55% never or rarely addressed this (Figure 1.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTreatment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver 80% of GPs consistently discussed toilet behavior and provided lifestyle advice to patients with anal fissures and hemorrhoids, compared to 59% for those with FI. (Table 2.)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHemorrhoids\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSixty-seven percent of the responders prescribes macrogol vs psylliumfibers (40%) in more than half of the cases. Twelve percent of the respondents referred to a PFPT in more than half of the cases for this complaint, while 26% almost never or never did. Fourteen percent of the GPs referred patients to a hospital for further treatment in at least half of the cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFissures\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor patients with acute anal fissures, macrogol was the prescribed laxative (71%), while psylliumfibers were prescribed in 29 % in more than half of the cases. In acute anal fissures, 30% of the responders always or almost prescribed lidocaine and Diltiazem (25%) of the cases. In case of chronic anal fissures, 70% of GPs prescribes macrogol in more than half of the cases, compared to 37% who prescribed psylliumfibers. Diltiazem was the preferred ointment for 68% of the respondents in more than half of the cases. In at least half of the cases, 33% of GPs referred patients with chronic anal fissures to a general hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFecal incontinence (FI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eForty-four percent prescribes psylliumfibers in more than half of the cases, compared to 16% who prescribed macrogol. Sixty-three percent referred patients to PFPT, and 51% to a hospital for FI in more than half of the cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor all kinds of proctological complaints, 85% of respondents preferred referring a patient to a surgeon, compared to 26% who opted for a gastroenterologist in more than half of the cases.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImplementation\u0026nbsp;\u003c/em\u003e\u003cem\u003eone-time consultation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEighty-two percent of GPs expressed willingness to explore the implementation of a one-time consultation by a PFPT, whereas only 3% were opposed to the idea. Reasons for implementing is too little time in the consulting room, (63% agreed), too little knowledge concerning proctological complaints (55% agreed) and 78% of the respondents\u0026rsquo; notices that they fail in performing a pelvic floor investigation. (Figure 2)\u003c/p\u003e\n\u003cp\u003eOver 85% agreed that a one-time consultation would contribute to optimal care. Additionally, 36% believed it would create more time during consultations, 46% expected cost reduction, and 49% anticipated shorter waiting times for hospital referrals. A large percentage of respondents from GPs (83%) want to start with a consultation of PFPT including therapy. Reasons for not implementing a one-time consultation included concerns about missing an underlying pathology (mentioned by five respondents) and a preference to manage the complaints themselves (mentioned by three respondents).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgeons\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e27 surgeons filled in the survey, 63% men. 44 % is colorectal surgeon, 59 % GE-surgeon and 11% residents. Eighty-two percent of the surgeons are willing to investigate a one-time consultation with a PFPT, while only 3% did not. Main reasons for implementing include insufficient qualification to perform pelvic floor assessments (reported by over 50% of respondents), limited consultation time (59%), time saving in current practice (70%), the potential for optimal care (82%), and cost reduction (63%). The reasons cited for not implementing this approach were concern about missing underlying pathologies and perceived insufficient expertise of PFPTs, each mentioned by two respondents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePelvic floor physical therapists\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFifty-six PFPTs filled in the survey. Hundred percent women of whom 73% had at least 10 years of experience as PFPT. Fifty seven percent of the respondents treated 10-30 patients per year with hemorrhoids, chronic anal fissure (43%) and FI (38%). Eighty-eight percent is willing to implement a one-time consultation. An important reason to implement is quality of care for (91% agreed), this is my expertise (88% agreed), right care at the right place (82% agreed). Reasons not to implement is for two PFPTs, too little time and waiting list.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGastroenterologists\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOnly six gastroenterologists filled in the questionnaire. Sixty-seven of them are willing to implement a one-time consultation. Main reason to implement is cost reduction, less time in the consulting room and quality of care.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eImplementation of Dutch guidelines\u003csup\u003e12,13\u003c/sup\u003e for GPs are generally followed. GPs see more patients with hemorrhoids per year compared to chronic anal fissure and fecal incontinence (FI). Besides a higher incidence of hemorrhoids, another reason could be that patients are more willing to go to a GP with complaints of loss of blood and swelling because they are more concerned about other underlying diseases. In contrary, anal pain or FI are probably more surrounded by shame, patients are too embarrassed to talk about and it is less asked for by a primary care providers.\u003csup\u003e19\u003c/sup\u003e\u0026nbsp; Asking for urological complaints in patients with proctological complaints was more common than asking for sexual problems. Although there is a strong relationship between sexual and /or physical abuse history in gastrointestinal disorders and pelvic floor disfunction\u003csup\u003e20,21\u003c/sup\u003e, only few GPs always or almost always ask for sexual complaints although it is recommended in the Dutch guideline for GPs.\u003csup\u003e13\u003c/sup\u003e A history of sexual and/or physical abuse may play a role in the divergence between the symptoms patients report and objective measurements and may alter treatment recommendations.\u003csup\u003e22\u003c/sup\u003e and is therefore an important topic of history taken.\u003c/p\u003e\n\u003cp\u003eA large percentage of GPs start with advices concerning lifestyle, toiletbehaviour and the use of fibers, which is in accordance to current guidelines.\u003csup\u003e12,13\u003c/sup\u003e This is an important finding of our study, because it is known that fiber intake of at least 25-35 grams per day will stabilize symptoms and diminish the risk of bleeding in patients with hemorrhoids with 50%.\u003csup\u003e23\u003c/sup\u003e\u0026nbsp; In patients with acute fissure, the use of fiber is effective in healing and should be recommended to ensure avoidance and constipation.\u003csup\u003e24,25\u003c/sup\u003e Although the requirement of daily fiber intake is around 35 to 40 g/d, the average diet contains less (12-18 g/d) and therefore a recommendation to use extra psylliumfibers should be kept in mind.\u003csup\u003e26\u003c/sup\u003e Research on the effect of psylliumfibers was found in a randomized study by Bliss \u003csup\u003e27\u003c/sup\u003e in 189 patients with FI. FI severity (calculated using number of FI episodes, consistency and amount of stool) was significantly better in the psyllium group. In our study, the advice of using psylliumfibers versus electrolytes was almost equal in half of the cases in patients with FI. A study of Bharucha\u003csup\u003e28\u003c/sup\u003e\u0026nbsp; investigated bowel patterns, rectal urgency, and daily routine influenced the occurrence of FI. Stool characteristics explained 46% of the likelihood for incontinence episodes. Lifestyle adjustments and advice among toiletbehaviour are recommended in the European Guideline for FI.\u003csup\u003e29\u003c/sup\u003e\u0026nbsp; although 27% of the GP respondents in our study gives these advices in less than half of the cases in patients with FI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most prescribed ointment was diltiazem in more than 50% of the cases. This is according to current guidelines. \u003csup\u003e30\u003c/sup\u003e Remarkably, the recommendation how to use the ointment differs between acute and chronic anal fissures in the current Dutch guideline.\u003csup\u003e13\u003c/sup\u003e It advises to insert the ointment into the anus for acute anal fissures and before defecation, in contrast with chronic anal fissures, apply it around the anus. The reason to use diltiazem is that calcium channel blockers relax the internal sphincter by blocking calcium influx to the cytoplasm of smooth muscle cells.\u003csup\u003e31\u003c/sup\u003e Therefore, it should be inserted into the anus, in chronic- as well as in acute anal fissures. A\u0026nbsp;correct application of the ointment (internally) is of crucial importance in case of relaxation and healing of the fissure.\u003c/p\u003e\n\u003cp\u003eThe Dutch guideline recommends performing digital rectal examination in patients with proctological complaints such as chronic anal fissures and hemorrhoids but only 47% of the GPs almost always or always perform this. In our study shows there is moderate consensus among the respondents concerning performing investigation of the pelvic floor muscles in patients with proctological complaints. Only 3% of the GPs always or almost always examined the pelvic floor muscles. This is even less than what was found in a recent survey on management of chronic anal fissure among gastrointestinal surgeons in the Netherlands, in which 37% of the respondents never or almost never examined the pelvic floor muscles.\u003csup\u003e32\u003c/sup\u003e Digital rectal examination including pelvic floor muscle investigation is needed to distinguish between different causes of proctological complaints.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOnly three percent of the respondents almost always or always referred patients to PFPT. \u0026nbsp;It is important to consider the systematic review by Kalkdijk et al. \u003csup\u003e34\u003c/sup\u003e which found that among patients with hemorrhoids, all reported straining during defecation prior to the onset of hemorrhoidal symptoms. Also, dyssynergic defecation was significantly more frequent in patients with hemorrhoids compared to healthy subjects. Treatment of underlying pelvic floor dysfunction e.g. dyssynergic defecation could be an important step to take and this could be more effective than treating hemorrhoids with surgery only.\u003csup\u003e34\u003c/sup\u003e Besides that, surgery could even be harmful by damaging the mucosal tissue which could result in soiling and pain.\u003csup\u003e35\u003c/sup\u003e In our study it was found that between 14-50% of the respondents patients were referred to a specialist depending on the diagnose, in more than half of the cases.\u0026nbsp;In case of referral, we found that GPs, preferred a surgeon\u0026nbsp;for proctological complaints. In a \u0026nbsp;recent survey in Italy among residents and young specialists was found that 75% of the respondents had to deal for the first time with proctological problems early on during their postgraduate training and a minority could practice proctology for a prolonged and continued period.\u003csup\u003e36\u003c/sup\u003e This could influence their skills of performing surgery and therefore the outcome of treatment and higher risk of recurrence when there is an underlying pelvic floor dysfunction. If this is the same for Dutch surgeons is not investigated.\u003c/p\u003e\n\u003cp skip=\"true\"\u003eGPs express their willingness to implement a one-time consultation for patients with common proctological complaints. Key motivations include time savings during consultations, limited knowledge regarding proctological conditions, the pursuit of optimal care, and potential cost reduction. In addition, surgeons, gastroenterologists and PFPTs are also positive concerning the implementation of a one-time consultation. Dutch PFPTs have the knowledge, skills and are trained to diagnose and treat a wide range of diagnosis related to pelvic floor dysfunctions. PFPTs have the time for history taking and to actively listen to the patients and provide education about complaints.\u003csup\u003e37\u003c/sup\u003e In current Dutch healthcare system, PFPT is not systematically integrated into the care pathway, and there is no structural reimbursement. Moreover, patients without supplementary insurance are required to pay for a consultation. \u0026nbsp;PFPTs could fill the gap between the GP and the specialist. Future studies are needed to assess whether a one-time consultation will lead to more focused treatment and efficiency and prevention of complaints. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003elimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA strength of this study is that participating GPs had a broad range of experience and have their practices in different parts of the Netherlands, in both cities and rural areas, which is probably a representative sample. However, we cannot extrapolate the answers of the Dutch GPs to other countries. Questions directed to the management of proctological complaints reflect their current practice and gives a clear inside the usual care but could have an influence on desirable answers. The number of patients with different proctological complaints was an estimation and not objectively measured by routine data or registration, this may have caused response-bias. The response rate of the gastro-intestinal surgeons and gastroenterologists was low; this may have caused non-response bias. Besides that, the questionnaire was sent with a link on a newsletter to members of the Dutch Coloproctology Working group that consist of members that have a large experience and affiliation in treating anorectal complaints, which could have caused selection bias. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research offers valuable insights in how Dutch GPs investigate, treat and refer patients with proctological complaints. Pelvic floor dysfunction is not consistently assessed and examined, and underlying pathophysiology could therefore be missed. GPs, PFPTs, gastrointestinal surgeons and gastroenterologist are positive concerning the implementation of a one-time consultation with a PFPT for common proctological complaints. Further research is needed to investigate the effect of the implementation of a one-time consultation of a PFPT in daily practice on quality of care, efficacy and efficiency of treatment of benign proctological complaints.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eGP\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Practioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003ePFPT\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePelvic Floor Physical Therapist\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eFI\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFecal Incontinence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Medical Ethical Committee of Leiden University Medical Center confirmed that formal ethical approval was not necessary under Dutch Law.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study does not involve human participants, human data, or human tissue. Therefore, the Declaration of Helsinki does not apply.\u0026nbsp;As ethics approval was not required for this minimal-risk study, informed consent was implied through voluntary completion of the survey. Participants were presented with an information statement outlining the study purpose, procedures, and data confidentiality before proceeding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData may be made available through formal data sharing agreement with the corresponding author ([email protected]) on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was obtained for the execution of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participating general practioners, surgeons, gastroenterologists and pelvic floor physical therapists for completing the questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNivel. 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Practice of proctology among general surgery residents and young specialists in Italy: a snapshot survey. Updates Surg Sep. 2023;75(6):1597\u0026ndash;605. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s13304-023-01540-5\u003c/span\u003e\u003cspan address=\"10.1007/s13304-023-01540-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAziz I, Whitehead WE, Palsson OS, Tornblom H, Simren M. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol Jan. 2020;14(1):39\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17474124.2020.1708718\u003c/span\u003e\u003cspan address=\"10.1080/17474124.2020.1708718\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6826199/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6826199/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eProctological complaints are very common and can significantly impair quality of life. It is not known how these problems are currently treated by general practioners (GPs). While most cases improve with conservative treatment, some persist or recur and require specialist referral. GPs rarely assess pelvic floor dysfunction, despite its potential contribution to recurring symptoms. A one-time consultation with a pelvic floor physical therapist could help to close this gap and improve care efficiency.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThe study aimed to evaluate current GP practices in managing proctological complaints, such as hemorrhoids, chronic anal fissure and fecal incontinence. Additionally, this study assessed the willingness of healthcare professionals to implement a one-time pelvic floor physical therapist consultation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eGPs completed a questionnaire on diagnostic approaches, treatment and referral habits. Gastrointestinal surgeons, gastroenterologists, pelvic floor physical therapists, and GPs were also surveyed about their attitudes toward introducing a pelvic floor physical therapist consultation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eResponses were received from 73 GPs, 27 surgeons, 6 gastroenterologists, and 56 pelvic floor physical therapists. GPs asked about urological problems in 36% and sexual complaints in only 7% of cases. Digital rectal examination was done by 47% of GPs, but only 3% assessed the pelvic floor muscles. Over 59% of GPs advised on lifestyle and toilet behaviour. In the past year, 47% referred 10\u0026ndash;25% of patients to a specialist. Support for a one-time pelvic floor physical therapist consultation was high among GPs (82%), surgeons (82%), gastroenterologists (66%), pelvic floor physical therapist (88%). Key reasons included time constraints, knowledge gaps, improved care, and cost-effectiveness.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003e Dutch GP-guidelines are generally followed. There is strong support for integrating a one-time pelvic floor physical therapist consultation into the care pathway for proctological complaints.\u003c/p\u003e","manuscriptTitle":"Current care for proctological complaints and pelvic floor physical therapy in a one-time consultation: a national survey among general practioners, surgeons, gastroenterologists and pelvic floor physical therapists","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 09:02:00","doi":"10.21203/rs.3.rs-6826199/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T05:19:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-26T22:44:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286529624257884297261151552828729211750","date":"2026-04-12T15:16:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T15:18:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71486419198254681363001488070443599824","date":"2026-03-28T22:17:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304250247492691354880965445050460528958","date":"2026-03-25T12:23:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T16:58:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266745785476513892107179559596552886691","date":"2026-03-14T10:59:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T11:38:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302481488914455219695164050415051377679","date":"2025-07-24T08:50:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-21T19:43:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T12:48:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T09:38:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-06-16T09:34:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f73230be-63b8-43ab-ab09-201b629b0659","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T06:39:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 09:02:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6826199","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6826199","identity":"rs-6826199","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}