Hemorrhoids are a common vascular condition involving cushions of tissue that line the anal canal, containing blood vessels, smooth muscle, and connective tissue. These cushions are a normal part of the anatomy, helping with anal continence. When these structures become enlarged and inflamed due to increased pressure, they can lead to uncomfortable symptoms. The most advanced and often most bothersome form is the prolapsed hemorrhoid.
Defining Prolapsed Hemorrhoids
Hemorrhoids are categorized based on their location relative to the dentate line, a sensory nerve boundary within the anal canal. Internal hemorrhoids form above this line, in the lower rectum, where they may initially be painless due to fewer pain-sensing nerves. External hemorrhoids develop below this line, under the skin around the anus, and are often more painful.
A prolapsed hemorrhoid is exclusively an internal hemorrhoid that has descended or pushed out of the anus. Prolapse describes the mechanism where the internal tissue, no longer held securely by weakened supports, slides downward and bulges outside the anal opening. Since external hemorrhoids are already on the outside, they do not prolapse. This protrusion causes the visible and sometimes painful symptoms associated with the condition.
The Four Grades of Prolapse
The severity of internal hemorrhoids is classified using a four-grade system based on the degree of prolapse, which helps determine the appropriate course of treatment. This system progresses from Grade I, which involves no prolapse, to Grade IV, which is a permanent protrusion.
A Grade I internal hemorrhoid involves enlarged tissue that may cause bleeding but remains entirely inside the anal canal. A Grade II hemorrhoid prolapses out of the anus during straining, such as during a bowel movement, but spontaneously retracts back inside once straining stops. The tissue reduces on its own without any manual assistance.
Grade III hemorrhoids prolapse out of the anus upon straining but require manual intervention to be pushed back inside. The patient must physically push the tissue back into the anal canal to achieve reduction. This inability to spontaneously reduce marks a significant increase in the severity of the condition.
The most advanced stage is the Grade IV hemorrhoid, which is permanently prolapsed outside the anus and cannot be manually pushed back inside. This exposed tissue can be at risk of complications like strangulation, where the blood supply is cut off.
Recognizable Symptoms and Causes
Symptoms often become more noticeable as the grade increases and the tissue protrudes further. A common symptom is bright red blood visible on the toilet paper or in the toilet bowl, usually occurring during or after a bowel movement. The most defining symptom is feeling or seeing a soft, often moist lump protruding from the anus.
The protruding tissue can also lead to anal itching, irritation, and discomfort, especially when sitting or during physical activity. A feeling of incomplete evacuation is also frequently reported. Pain is not always a feature of internal hemorrhoids unless the prolapsed tissue becomes thrombosed or strangulated.
The primary cause of hemorrhoid formation and subsequent prolapse is increased pressure within the anal and rectal veins. Chronic constipation, straining during bowel movements, and prolonged sitting on the toilet are frequent contributors. Other risk factors that increase intra-abdominal pressure include pregnancy and obesity.
Options for Management and Treatment
Treatment for prolapsed hemorrhoids is determined by the grade of the condition, following a tiered approach from least to most invasive. For Grade I and many Grade II hemorrhoids, conservative management is the initial approach. This involves lifestyle modifications such as increasing dietary fiber and fluid intake to soften stools and minimize straining.
Topical treatments, including over-the-counter creams and ointments containing hydrocortisone, can reduce inflammation and relieve discomfort. Warm sitz baths, where the anal area is soaked in warm water for 10 to 15 minutes several times a day, can help soothe irritation and muscle spasms. These conservative measures aim to manage symptoms and prevent further progression.
If conservative care fails, or for higher-grade hemorrhoids (Grades II and III), minimally invasive office procedures are often effective.
Minimally Invasive Procedures
Rubber band ligation is a common technique where a small elastic band is placed around the base of the hemorrhoid to cut off its blood supply, causing the tissue to wither and fall off within a week. Sclerotherapy involves injecting a chemical solution directly into the hemorrhoid to shrink it. Infrared coagulation uses heat to create scar tissue that reduces the blood supply.
Surgical intervention is typically reserved for severe, symptomatic Grade III hemorrhoids that fail to respond to office procedures and for all Grade IV cases. A traditional hemorrhoidectomy involves surgically excising the enlarged hemorrhoidal tissue, which is considered the most definitive treatment with the lowest recurrence rate. Another option, stapled hemorrhoidopexy, uses a circular stapling device to reposition the prolapsed tissue back into the anal canal and cut off its blood supply.