Hemorrhoids are vascular cushions—collections of blood vessels, connective tissue, and muscle—that are a normal part of the human anatomy in the anal canal. They become a medical concern, often called piles, when these cushions become swollen or inflamed due to increased pressure. Internal hemorrhoids develop in the upper anal canal, above the dentate line. Because of this location, they are typically not visible from the outside and often do not cause discomfort unless they progress. The primary visual characteristic of internal hemorrhoids is how far they protrude or prolapse out of the anal opening during straining.
The Grading System: How Internal Hemorrhoids Are Classified
The medical community classifies internal hemorrhoids based on the degree to which they descend from their normal position, which directly answers the question of what they look like at various stages. This standardized four-grade system, known as the Goligher classification, is defined by the hemorrhoid’s behavior during a bowel movement. This classification determines the severity and guides treatment decisions.
A Grade I internal hemorrhoid protrudes slightly into the anal canal but does not move outside the anal opening. The hemorrhoid remains completely inside the body, meaning there is no external visual appearance. Grade II hemorrhoids prolapse, or push out, during defecation or straining, but they spontaneously retract back into the anal canal once the person relaxes.
Grade III hemorrhoids prolapse outside the anal opening and require manual replacement. Unlike Grade II, these swollen cushions remain outside until they are physically pushed back inside. The most advanced stage is Grade IV, where the hemorrhoids are permanently prolapsed and cannot be manually pushed back in. These severe protrusions can sometimes involve both internal and external components, presenting as a constant mass of tissue outside the anus.
Recognizing Internal Hemorrhoids: Symptoms Beyond Appearance
Since the lower grades of internal hemorrhoids remain hidden inside the body, their presence is usually signaled by specific symptoms rather than a visible lump. The most common sign is painless rectal bleeding, which is typically bright red. This color indicates the blood is fresh and comes from the fragile vascular lining of the internal hemorrhoid near the anal opening.
This bleeding is usually noticed on the toilet paper after wiping, streaked on the surface of the stool, or dripping into the toilet bowl. The absence of pain occurs because the tissue lining the upper anal canal has visceral innervation, which does not transmit pain signals like the skin does. Other indications include a sensation of incomplete evacuation or the presence of a clear or white mucus discharge produced by the rectal lining.
Internal Versus External: Understanding the Anatomical Difference
Distinguishing internal hemorrhoids from their external counterparts is essential because their locations determine their symptoms and visual characteristics. The separation point is the dentate line, a jagged border located a few centimeters inside the anal canal. Internal hemorrhoids originate above this line, covered by the rectal mucosa, which is moist, smooth, pinkish tissue.
External hemorrhoids develop below the dentate line and are covered by anoderm, which is modified, highly sensitive skin. This anatomical difference explains the sensory distinction: internal hemorrhoids are typically painless because the rectal mucosa has only autonomic nerve supply. External hemorrhoids are innervated by somatic nerves, meaning they can cause significant pain, especially if a blood clot forms within them. While internal hemorrhoids appear as reddish, smooth bulges when prolapsed, external hemorrhoids are covered by skin, often appearing as a bluish lump if thrombosed.
Initial Management and When to Seek Professional Diagnosis
Initial management for internal hemorrhoids, especially Grade I and Grade II cases, focuses on conservative lifestyle and dietary adjustments to minimize straining. Increasing dietary fiber intake (25 to 35 grams per day) is a primary step, often supported by fiber supplements. Maintaining high fluid intake, specifically water, helps to soften the stool and reduce the need for excessive force during defecation.
Warm water soaks, frequently called sitz baths, can help soothe the anal area and reduce irritation. Over-the-counter topical treatments, such as creams or suppositories containing hydrocortisone or witch hazel, may provide temporary relief from itching or minor inflammation. It is important to seek professional diagnosis if bleeding is heavy, or if the blood is dark or mixed with the stool, as these can be signs of other digestive conditions. Any Grade IV hemorrhoid (permanently prolapsed and irreducible) or symptoms that do not improve after a week of consistent home care warrant an examination to rule out more serious issues.