Hemorrhoids are vascular cushions in the lower rectum and anus. When the veins within them swell and become inflamed, they can cause discomfort, bleeding, and sometimes protrude outside the anal canal. This protrusion is called prolapse, occurring when the internal hemorrhoid tissue and its supporting structures weaken and shift downward. The reason a prolapsed hemorrhoid may not return inside is directly related to the extent of this structural breakdown, which determines the condition’s severity.
Understanding the Grades of Prolapse
The severity of an internal hemorrhoid is categorized by a four-grade classification system, which describes how far the tissue bulges and whether it can retract. Grade I hemorrhoids do not prolapse outside the anus and typically remain inside the anal canal, primarily causing symptoms like painless bleeding.
A Grade II hemorrhoid protrudes outside the anal canal, often during a bowel movement or straining, but then spontaneously retracts back inside once straining stops. The supporting tissue is still elastic enough to pull the cushion back into its normal position.
Grade III hemorrhoids prolapse outside the anus but require manual manipulation to return to their normal internal position. The supporting structures have deteriorated significantly enough that spontaneous retraction is no longer possible.
The most severe form is a Grade IV hemorrhoid, which is permanently prolapsed and cannot be manually pushed back inside the anal canal. This irreversible protrusion often causes substantial pain and hygiene difficulties.
Primary Causes and Contributing Factors
The underlying cause of hemorrhoid development and prolapse is increased pressure in the lower rectum. The most significant factor is chronic straining during bowel movements, which pushes the swollen tissue downward and weakens the anchoring support. This straining is frequently linked to chronic constipation or prolonged bouts of diarrhea, both of which increase the force exerted on the rectal veins.
Prolonged sitting, particularly on the toilet, is also a major contributor because it increases pressure on the rectal veins. Other conditions that consistently elevate intra-abdominal pressure also increase the risk of prolapse. These include obesity, pregnancy, and regular heavy lifting, all of which put added strain on the tissues that hold the hemorrhoids in place. Over time, this repeated pressure damages the connective tissue, allowing the internal hemorrhoidal cushions to enlarge and slip out.
Immediate Relief and At-Home Management
For immediate relief from a prolapsed hemorrhoid, especially Grade III, gentle manual reduction is often necessary. This involves carefully pushing the tissue back into the anal canal using light pressure and clean hands, as excessive force can cause further irritation.
Soaking the area in a warm sitz bath for 10 to 15 minutes, two to three times a day, is recommended to reduce swelling and soothe discomfort. The warm water helps relax the anal sphincter and promotes blood flow, which aids healing.
Over-the-counter topical treatments provide temporary relief from itching and pain. Look for creams or ointments containing witch hazel, which acts as an astringent, or hydrocortisone, a mild steroid that reduces inflammation. Steroid products should only be used for about one week unless directed by a healthcare provider, as prolonged use can thin the skin. To prevent further irritation and straining, soften stools by increasing dietary fiber intake to 20 to 35 grams per day and ensuring adequate hydration.
When to Seek Medical Intervention and Professional Treatments
While at-home management is effective for many cases, certain symptoms require prompt medical attention. Seek immediate care if you experience severe, unrelenting pain, significant or persistent rectal bleeding, or if the prolapsed hemorrhoid becomes hard, purple, and cannot be pushed back inside. These symptoms can indicate complications such as a thrombosed hemorrhoid (a blood clot forms within the tissue) or strangulation, where the blood supply is cut off. Strangulation is a medical emergency.
When conservative treatments fail, or for Grade III and Grade IV prolapse, a healthcare professional can offer several office-based or surgical procedures. Minimally invasive, office-based treatments are often the first line of defense for persistent Grade II and Grade III hemorrhoids.
Office-Based Procedures
Rubber band ligation involves placing a small elastic band around the base of the hemorrhoid to cut off its blood supply, causing the tissue to shrink and fall off within about a week.
Sclerotherapy is another non-surgical option where a chemical solution is injected directly into the hemorrhoid tissue, causing it to scar and shrink.
Surgical Options
For severe Grade IV prolapse or when other treatments have been unsuccessful, surgical options, such as a hemorrhoidectomy, are typically necessary. This procedure involves the surgical removal of the excess tissue and offers the highest long-term success rate for permanently prolapsed hemorrhoids.