Hemorrhoids are swollen and inflamed veins that develop in the lower rectum and anus, causing bleeding, discomfort, and itching. The primary concern for many is the phenomenon of a hemorrhoid “popping out” or protruding from the anal opening. This specific issue is almost exclusively associated with internal hemorrhoids, which originate higher up in the anal canal. The protrusion, medically known as prolapse, signifies a progression in the condition that requires a clear understanding of its severity.
Defining Internal Versus External Hemorrhoids
The distinction between internal and external hemorrhoids is based on their location relative to the dentate line, a boundary within the anal canal. Internal hemorrhoids form above this line, where the nerve endings are sparse, meaning they typically cause little to no pain. Their most common symptom is painless, bright red bleeding during a bowel movement.
These internal hemorrhoids are the ones capable of prolapsing because they are located within the anal canal and can be pushed downward by straining. Conversely, external hemorrhoids form below the dentate line, under the skin around the anus, an area rich in pain-sensing nerves. External hemorrhoids are often felt as painful, sensitive lumps.
Understanding Hemorrhoid Prolapse Grades
The progression of an internal hemorrhoid’s protrusion is measured using a standardized classification system with four distinct grades. This grading system is based on the extent to which the hemorrhoidal tissue protrudes from the anal canal and whether it returns to its normal position.
Grade I represents the least severe form, where the hemorrhoids remain internal and do not protrude outside the anus at all. Grade II hemorrhoids push out during straining but spontaneously retract back inside once the straining stops.
A Grade III hemorrhoid protrudes outside the anal opening but does not go back inside on its own, requiring the individual to manually push the tissue back into the anal canal. The most severe category is Grade IV, where the hemorrhoid is permanently prolapsed and cannot be manually pushed back inside.
Immediate Action When Prolapse Occurs
When a hemorrhoid prolapses, especially Grade III, the immediate goal is to reduce swelling and gently return the tissue to its normal position inside the anal canal. Sitting in a warm sitz bath for 10 to 15 minutes a few times a day can help soothe the area and reduce inflammation. Applying a cold compress or ice pack wrapped in a cloth to the area can also help shrink the swollen tissue.
If the prolapsed tissue is a Grade III hemorrhoid, a gentle attempt at manual reduction can be made by applying steady, soft pressure to push it back inside. However, if the prolapse is accompanied by severe, continuous pain and the tissue appears trapped or dusky in color, immediate medical attention is necessary. This can signal strangulation, a serious complication where the anal sphincter muscles cut off the blood supply to the prolapsed tissue, potentially leading to tissue death.
Professional Treatment Pathways
For hemorrhoids that do not respond to conservative home measures, medical interventions are available and are typically matched to the prolapse grade. Grade I and Grade II internal hemorrhoids are often treated with minimally invasive, non-surgical office procedures.
The most common of these is rubber band ligation (RBL), where a small band is placed around the base of the hemorrhoid to cut off its blood supply, causing the tissue to wither and fall off. Sclerotherapy is another office-based option, involving the injection of a chemical solution into the hemorrhoid to shrink it.
For persistent Grade III and all Grade IV hemorrhoids, surgical options are typically recommended. The standard surgical removal is a hemorrhoidectomy, which excises the excess tissue that causes the bleeding and protrusion. An alternative is stapled hemorrhoidopexy, which blocks the blood flow to the hemorrhoidal tissue.