Anal fissure presenting alongside reduced anal sphincter tone represents a distinct clinical sub-population. The fissure may be anteriorly located or occur as multiple lesions — features that, combined with the pressure phenotype, shape how management is sequenced.
Low sphincter pressure is characterised by anal sphincter pressures below those considered normal, assessed clinically and/or manometrically. In this context, the fissure may be anterior in position or present as multiple lesions, distinguishing it from the more common posterior hypertonic pattern and necessitating a tailored approach.
When conservative measures have not led to resolution, a surgical flap-based technique may be among the options considered in appropriate candidates with this pressure phenotype. The complete decision pathway — including patient selection, sequencing, and all relevant factors — is set out in the full protocol.
DOI: 10.1111/codi.167