From the Guidelines
For an 84-year-old female with an anal fissure, I recommend starting with conservative management, focusing on stool softeners, sitz baths, and topical therapy with calcium channel blockers like diltiazem 2% ointment, as they have been shown to be effective with fewer side effects compared to nitroglycerin 1. Begin with sitz baths (warm water soaks) for 10-15 minutes, 2-3 times daily.
- Use a stool softener like docusate sodium 100mg twice daily to prevent constipation.
- Apply topical diltiazem 2% ointment to the anal area 3 times daily for 6-8 weeks; this relaxes the internal anal sphincter and improves blood flow to promote healing.
- Ensure adequate fiber intake (25-30g daily) and hydration (6-8 glasses of water). For pain management, acetaminophen is preferred over NSAIDs, especially in elderly patients. If conservative measures fail after 8-12 weeks, consider referral for botulinum toxin injection or surgical options like lateral internal sphincterotomy, though surgery carries higher risks in elderly patients. Conservative approaches are particularly important in elderly patients as they have less tissue elasticity and may heal more slowly, while also being more vulnerable to medication side effects and surgical complications. Given the most recent evidence from 2021 1, calcium channel blockers are recommended due to their effectiveness and lower risk of side effects compared to other topical therapies.
From the Research
Treatment Options for Anal Fissure
- Conservative management using increased fiber and warm baths can result in healing of approximately half of all anal fissures 2
- Pharmacologic options such as topical nifedipine, nitroglycerin ointment, and calcium channel blockers (e.g. diltiazem) can be effective in healing anal fissures, with varying success rates 3, 4, 5
- Surgical options, including lateral internal sphincterotomy, are available for fissures that fail conservative care, with lateral internal sphincterotomy being the gold standard for definitive management of anal fissure 2, 3
Considerations for an 84-year-old Female
- Age may be a factor in considering treatment options, with older adults potentially being more susceptible to side effects from certain medications or having increased risk with surgical procedures
- Conservative management may be a preferred initial approach, given the potential risks associated with surgery in older adults
- Topical treatments such as diltiazem or nifedipine may be considered, as they have been shown to be effective in some cases and may have fewer side effects than other options 3, 5
Efficacy of Treatment Options
- Lateral internal sphincterotomy has been shown to have a high success rate, with 88.2% of patients achieving healing of the fissure at 8 weeks in one study 3
- Topical nifedipine has been shown to be effective, with 68.9% of patients achieving healing of the fissure at 8 weeks in one study 3
- Diltiazem has been shown to be effective in patients who have failed previous treatment with glyceryl trinitrate, with 48% of patients achieving healing of the fissure at 8 weeks in one study 5