Hemorrhoids are a common medical condition involving the swelling and irritation of blood vessels in the lower rectum and anus. These vascular cushions are a normal part of the anatomy but become problematic when subjected to excess pressure, often from straining during bowel movements, pregnancy, or chronic constipation. Approximately half of all people experience symptomatic hemorrhoids by the age of 50. Hemorrhoids are categorized based on their location: internal hemorrhoids form inside the rectum, and external hemorrhoids develop under the skin around the anal opening.
The Hemorrhoid Grading System
The severity of internal hemorrhoids is classified using a four-grade system based on the degree to which the tissue protrudes, or prolapses, outside the anal canal. This system guides both diagnosis and the selection of an appropriate treatment plan.
Grade 1 hemorrhoids swell but remain inside the anal canal, causing symptoms like bleeding but no protrusion. Grade 2 hemorrhoids prolapse during straining but then spontaneously retract back inside once the straining ceases. Grade 4 is the most severe, representing a hemorrhoid that is permanently prolapsed and cannot be manually pushed back inside. This classification system provides a consistent measure of disease progression.
Defining Grade 3 Characteristics
When considering the size of a Grade 3 hemorrhoid, the measurement is based on its functional behavior and degree of prolapse, not its diameter. The defining characteristic is that the tissue protrudes outside the anus during defecation or straining and will not return to its internal position on its own.
Instead, the individual must physically push the prolapsed tissue back into the anal canal using a finger, an action known as manual reduction. A Grade 3 hemorrhoid often presents with discomfort, pain, and a feeling of incomplete evacuation.
Other common symptoms include bright red rectal bleeding, a noticeable lump outside the anus, mucus discharge, or anal itching. If left untreated, the tissue may become trapped or strangulated, potentially progressing to a Grade 4.
Treatment Options for Grade 3
Because Grade 3 hemorrhoids require manual reduction, they typically need more than just conservative lifestyle changes, though these modifications remain foundational. The standard approach involves minimally invasive office-based procedures.
Rubber band ligation (RBL) is a common initial choice, involving placing a small elastic band around the base of the hemorrhoid to cut off its blood supply. This causes the tissue to shrink and fall off within a few days.
Another option is sclerotherapy, where a chemical solution is injected to shrink and scar the hemorrhoidal tissue. While RBL is effective, it may require multiple sessions, and recurrence rates can be a concern.
For larger Grade 3 hemorrhoids, or those that fail to respond to office procedures, surgical hemorrhoidectomy is often the most effective treatment, offering the lowest recurrence rates. Other surgical techniques, such as stapled hemorrhoidopexy or hemorrhoidal artery ligation, may also be considered.