Hemorrhoids are swollen veins located in the rectum or anus, similar to varicose veins. While generally not serious, they can cause uncomfortable symptoms. Internal hemorrhoids, which form inside the rectum, can move out of the anal canal, a process known as prolapse. This makes them visible or “external” and can lead to various issues, from mild discomfort to significant pain.
Internal vs. External Hemorrhoids
Hemorrhoids are categorized based on their location relative to the dentate line, a boundary within the anal canal. Internal hemorrhoids develop above this line, inside the rectum. They are typically not visible or palpable from the outside and, due to fewer pain-sensing nerves, often cause no pain unless they prolapse. The most common symptom of internal hemorrhoids is painless bright red bleeding during or after bowel movements.
External hemorrhoids, by contrast, form below the dentate line, under the skin around the anus. This area contains numerous pain-sensing nerves, making external hemorrhoids more likely to cause discomfort, itching, and pain. They often appear as soft lumps near the anus and can be seen or felt. While external hemorrhoids can also bleed, they are particularly prone to forming blood clots, known as thrombosed hemorrhoids, which can lead to sudden, severe pain and swelling.
How Internal Hemorrhoids Can Protrude
Prolapse of internal hemorrhoids occurs when their supporting tissues weaken, often due to increased pressure in the rectal area. Factors contributing to this increased pressure include straining during bowel movements, chronic constipation or diarrhea, prolonged sitting (especially on the toilet), pregnancy, and obesity. Aging also plays a role, as supporting tissues naturally weaken over time.
The extent of prolapse in internal hemorrhoids is classified into four grades: Grade I hemorrhoids remain inside the anal canal and do not prolapse, though they may bleed. Grade II hemorrhoids protrude during straining but spontaneously retract back inside the anus afterward. Grade III hemorrhoids prolapse and require manual pushing to be reinserted into the anal canal. Grade IV hemorrhoids are permanently prolapsed and cannot be manually pushed back inside.
Recognizing Prolapsed Hemorrhoids and Their Issues
When an internal hemorrhoid prolapses, it can manifest as a soft lump or mass bulging outside the anus, which may be skin-colored or reddish-pink. Individuals might experience a sensation of fullness or an urge to have a bowel movement even after emptying their bowels. Other common symptoms include itching, irritation, and discomfort around the anal region. Bleeding may persist, and some individuals might notice mucus discharge.
Prolapsed hemorrhoids can lead to several complications. One significant concern is thrombosis, where a blood clot forms within the prolapsed hemorrhoid, causing acute and often severe pain, swelling, and a hard, discolored lump. Another serious complication is strangulation, which occurs when the anal muscles cut off the blood supply, potentially leading to intense pain and tissue damage. In rare cases, severe bleeding can contribute to anemia.
Addressing Prolapsed Hemorrhoids
Initial management of prolapsed hemorrhoids often involves lifestyle and dietary adjustments. Increasing dietary fiber through fruits, vegetables, and whole grains, along with adequate hydration, helps soften stools and reduce straining. Short, warm sitz baths can reduce inflammation and soothe discomfort. Over-the-counter topical creams and ointments with hydrocortisone or witch hazel may provide temporary relief from itching and swelling.
Seek medical attention if symptoms persist or worsen, if there is significant bleeding, or if the prolapsed hemorrhoid cannot be reduced. Medical treatments for persistent or severe prolapsed hemorrhoids include rubber band ligation, which cuts off blood supply to shrink the hemorrhoid, and sclerotherapy, involving an injected solution to shrink it. For advanced cases, surgical removal (hemorrhoidectomy) may be recommended, particularly for Grade IV hemorrhoids or those with severe complications.