Hemorrhoids are swollen veins located in the lower rectum and anus. These vascular cushions become symptomatic when they swell, stretch, or become inflamed. The severity of hemorrhoidal disease is categorized using a standardized grading system. This classification helps determine the degree of tissue prolapse and select the most appropriate treatment path. The most severe form, Grade 4, represents a significant progression of the condition.
Characteristics of Stage 4 Hemorrhoids
Stage 4 hemorrhoids are defined by the permanent prolapse of the hemorrhoidal tissue outside the anal canal. This tissue cannot be manually pushed back inside, a state known as irreducible prolapse. The constant presence of tissue outside the body leads to significant irritation and discomfort. This persistent exposure to clothing and friction often results in chronic inflammation and surface erosion.
Patients frequently experience constant, severe pain that impacts daily activities and sitting. Significant bleeding is common, often manifesting as bright red blood coating the stool or dripping into the toilet. Mucous discharge and intense anal itching (pruritus ani) contribute to the patient’s distress. The tissue’s inability to return inside the anus makes symptoms persistent rather than intermittent.
A major complication is acute thrombosis, the formation of a blood clot within the prolapsed vein. Thrombosed hemorrhoids cause a sudden increase in pain and present as hard, tender lumps. The condition also carries a risk of strangulation, where the muscles of the anal sphincter constrict the base of the prolapsed tissue. This constriction cuts off the blood supply, leading to tissue death (gangrene) if not addressed immediately.
The mechanical integrity of the supporting structures, such as the suspensory ligaments, has completely failed at this stage. This structural breakdown is why manual reduction attempts are unsuccessful and why the condition is considered irreversible without medical intervention. The extent of the prolapsed tissue, which often includes both internal and external components, necessitates a definitive treatment approach to resolve the underlying anatomical defect.
How Stage 4 Compares to Milder Stages
The grading system, known as the Goligher classification, categorizes the disease based on the degree of prolapse. Grade 1 hemorrhoids remain entirely internal, bleeding but never protruding. Grade 2 hemorrhoids prolapse outside the anus during straining, such as during a bowel movement, but spontaneously retract back inside afterward. The tissue in these milder stages maintains a degree of functional elasticity and support.
The progression to Grade 3 marks a significant loss of structural support for the venous cushions. In this stage, the hemorrhoids prolapse during defecation and require the individual to physically push them back into the anal canal. This manual reduction provides temporary relief, but the tissue will prolapse again with the next strain or activity.
Grade 4 is distinguished from Grade 3 specifically by the failure of manual reduction. The tissue is fixed outside the body, representing the final stage of this anatomical deterioration. This permanent exterior position makes Grade 4 the most symptomatic and least responsive to non-surgical treatments compared to the earlier, reducible grades.
Medical Interventions for Severe Hemorrhoids
Given the permanent nature and high complication risk of Grade 4 hemorrhoids, conservative management methods offer little long-term success. Dietary changes and topical creams may alleviate some acute symptoms but cannot correct the underlying structural prolapse. Definitive surgical intervention is almost always necessary to physically remove or reposition the diseased tissue. The selection of the specific procedure depends on the size of the hemorrhoids and the surgeon’s expertise.
The traditional approach for severe disease is the excisional hemorrhoidectomy, which involves cutting away the excess tissue. This procedure is highly effective, offering the lowest recurrence rates for Grade 4 hemorrhoids. While definitive, excisional hemorrhoidectomy is associated with a more painful and prolonged recovery, often requiring two weeks for patients to return to daily activities.
Another technique is the stapled hemorrhoidopexy, also known as the Procedure for Prolapse and Hemorrhoids (PPH). This method uses a circular stapling device to remove a ring of mucosa and submucosa above the hemorrhoidal complex. The stapling simultaneously lifts the prolapsed tissue back into position and interrupts the blood supply. PPH typically results in less post-operative pain and a quicker return to normal activities compared to the traditional excisional method.
A third option is Transanal Hemorrhoidal Dearterialization (THD) or Hemorrhoidal Artery Ligation (HAL). This procedure uses a specialized Doppler probe to locate the arteries supplying blood to the hemorrhoids. The surgeon then stitches the arteries to cut off the blood flow, causing the hemorrhoids to shrink. This method is often combined with a procedure called mucopexy to lift and secure the prolapsed tissue back into place.
Post-operative care focuses on managing pain, preventing constipation, and ensuring proper wound healing. Patients are advised to use stool softeners and fiber supplements to keep bowel movements soft during recovery. The aim of these surgical treatments is to eliminate pain, stop bleeding, and restore the normal structure of the anal canal.