Dear Editor,

We would like to comment upon the article “Posterior perineal support as treatment for anal fissures-preliminary results with a new toilet seat device” from Tan et al. published in 2009 in Techniques in Coloproctology [1].

The use of a posterior perineal support to facilitate defecation has been described earlier. This support can be a special device (Defecom® [2, 3]), a board with a 3-inch hole [4] or just the posterior part of the toilet seat itself if the patient sits with her/his posterior perineum on it (anti-sagging test [5]). Maybe the Colorec® device has a more effective design to support the posterior perineum during defecation. Did the authors compare their device with these older methods?

The perineal descent has not been evaluated in this study. Because there is a clear link between this descent and dyschezia [6] (but also with dyspareunia, urinary and faecal incontinence, dysuria, genital prolapse and the clinical signs of pudendal neuropathy), it should be logical to have better results with this method in patients with a perineal descent of more than 1.5 cm (measured with a Perineocaliper®) [5]. It means also that the Colorec® should not only reduce the problems associated with anal fissures but also all the symptoms linked with an abnormal perineal descent [5] and even the descent itself by improving the defecation process (the vicious circle being interrupted).

Because pudendal neuropathy can induce neurogenic modifications of the skin and anal dysfunction [7–9] and because it is more frequent in case of abnormal perineal descent, it would be also interesting to search for the three clinical signs of pudendal neuropathy (hyper or hyposensibility of the skin using a pinprick test, painful skin rolling test of the perineum and painful pudendal nerve during vaginal or rectal examination) in patient with anal fissures [7, 10, 11]. This neuropathy could improve thanks to the reduction of the perineal descent and, inversely, the treatment of the neuropathy itself could theoretically help the anal fissure to heal.

In conclusion, Colorec® could be useful in Perineology. We suggest further studies including the measurement of perineal position and descent, search for the three clinical signs of pudendal neuropathy and an evaluation of colo-proctologic together with gynaecological and lower urinary tracts symptoms [12].