Hemorrhoids are vascular cushions that naturally exist within the anal canal. When these cushions become inflamed and swollen due to increased pressure, they develop into hemorrhoidal disease. Prolapse refers to the swollen tissue descending or slipping out of its normal anatomical position and protruding from the anus.
The Difference Between Internal and External Hemorrhoids
Hemorrhoids are classified based on their location relative to the dentate line, a jagged anatomical boundary situated in the anal canal. Internal hemorrhoids form above this line, while external hemorrhoids form below it, underneath the sensitive skin of the anus. This distinction is important because the tissue above the dentate line has few pain-sensing nerves, meaning internal hemorrhoids often cause symptoms like bleeding or a feeling of fullness. Conversely, external hemorrhoids form in an area rich with cutaneous nerves, making them highly painful when they swell, especially if a blood clot forms within them, a condition known as thrombosis.
Only internal hemorrhoids are capable of prolapsing, or pushing outward, because they originate higher up in the anal canal. External hemorrhoids are already located on the exterior, and they simply swell in place rather than descending or slipping out. When the internal vascular cushion loses its structural support due to prolonged straining or pressure, it can be forced down and out through the anal opening, becoming a prolapsed hemorrhoid.
Visual Description of Prolapsed Hemorrhoids
A prolapsed hemorrhoid presents visually as a soft, moist, cushion-like lump or mass of tissue protruding from the anal opening. The size can vary significantly, ranging from a small, pea-sized nodule to a larger mass comparable to the size of a grape or even a small plum in more severe cases. This protrusion is often irregular in shape, appearing as distinct, sometimes lobulated, clusters of swollen tissue.
A healthy, non-complicated prolapse will typically appear pink or reddish-pink, reflecting the color of the moist mucous membrane that covers it. If the prolapsed hemorrhoid has become thrombosed, meaning a blood clot has formed inside the vein, its appearance darkens considerably. The lump will look dark purple or bluish due to the pooled blood beneath the surface.
The texture of the protruding mass is usually smooth and soft to the touch, but the surrounding area may show signs of irritation. Because the tissue is now outside the protective anal canal, it can become inflamed, leading to swelling and a shiny, taut appearance. Persistent prolapse can also lead to chronic irritation, resulting in a mucus discharge and dampness around the perianal skin.
Understanding the Severity (Grading System)
To accurately classify the degree of prolapse and guide treatment decisions, medical professionals use a four-point grading system specific to internal hemorrhoids. Grade I hemorrhoids are the least severe, characterized by bleeding but no actual prolapse of the tissue outside the anal canal.
The progression to Grade II occurs when the hemorrhoid prolapses or protrudes from the anus during straining, such as during a bowel movement. Crucially, Grade II hemorrhoids retract or go back inside the anal canal on their own once the straining ceases, often spontaneously after defecation.
Grade III hemorrhoids represent a more advanced stage of prolapse, where the tissue protrudes during straining but does not return to its internal position naturally. These require manual intervention, meaning the individual must gently push the prolapsed tissue back inside the anal canal with a finger.
The most severe form is Grade IV hemorrhoids, which are characterized by permanent and irreducible prolapse. This tissue remains constantly outside the anus and cannot be manually pushed back in. Grade IV prolapse can be intensely painful, particularly if the blood supply to the tissue is cut off, a complication known as strangulation.
Next Steps and When to See a Doctor
While many early-stage hemorrhoids can be managed with dietary changes and over-the-counter remedies, certain signs indicate the need for medical consultation. If you notice rectal bleeding, it is recommended to see a doctor to ensure the bleeding is definitively from hemorrhoids and not a sign of a more serious condition, such as colorectal cancer. Continuous or severe bleeding warrants immediate medical attention.
Sharp, constant, or debilitating pain is another important indicator, especially in the case of a thrombosed or strangulated hemorrhoid. A thrombosed hemorrhoid forms a painful lump that may require urgent medical care for pain management and to prevent complications. Furthermore, if a prolapsed hemorrhoid is Grade IV and cannot be reduced, or if it is accompanied by fever or signs of infection like pus or discharge, seek prompt evaluation.
If the discomfort, pain, or protrusion persists for more than a week despite home care efforts, a consultation is necessary. Only a medical professional can accurately grade the severity of the prolapse and recommend the most effective treatment, which can range from in-office procedures like rubber band ligation for Grades I-III to surgical options for Grade IV hemorrhoids.