A prolapsed hemorrhoid is an internal hemorrhoid that has swollen enough to slip out through the anal opening. Internal hemorrhoids normally sit inside the anal canal, where they’re anchored to the underlying muscle by a supportive ligament. When that support weakens or the tissue swells from repeated pressure, the hemorrhoid can descend and protrude outside the body, especially during a bowel movement.
How Prolapse Differs From External Hemorrhoids
People often confuse a prolapsed hemorrhoid with an external hemorrhoid because both can be felt or seen outside the anus. But they’re different structures with different characteristics. A prolapsed hemorrhoid is internal tissue that has pushed outward. It’s covered in mucosa, the same moist lining found inside the rectum, which isn’t particularly sensitive to touch or pain. An external hemorrhoid, by contrast, develops under the skin surrounding the anus. That skin is highly sensitive, which is why external hemorrhoids tend to hurt more from the start. A symptomatic external hemorrhoid often appears as a bluish, painful lump just outside the anus.
If you feel soft, moist tissue protruding during or after a bowel movement, and it either slides back in on its own or can be gently pushed back, that’s likely a prolapsed internal hemorrhoid rather than an external one.
Grades of Prolapse
Doctors classify internal hemorrhoids into four grades based on how far the tissue has descended:
- Grade I: The hemorrhoid bulges into the anal canal but doesn’t come out. You won’t feel it externally, though it may bleed.
- Grade II: The tissue protrudes during a bowel movement but pulls back inside on its own afterward.
- Grade III: The hemorrhoid comes out and stays out until you manually push it back in.
- Grade IV: The tissue remains permanently outside the anus and can’t be pushed back in.
This grading system matters because it determines which treatments are appropriate. Lower grades often respond to conservative measures, while higher grades are more likely to need a procedure.
What Causes the Tissue to Prolapse
The short answer is pressure. Anything that increases pressure inside the abdomen or around the anal canal can gradually stretch and weaken the tissue that holds hemorrhoids in place. Chronic constipation is the most common culprit: straining during a bowel movement pushes the hemorrhoids against the sphincter muscle while also interfering with normal blood flow. The blood pools and enlarges the vessels over time.
Prolonged sitting on the toilet has a similar effect. Pregnancy increases intra-abdominal pressure directly, and being overweight adds sustained pressure throughout the day. Aging also plays a role because the mucosal suspensory ligament that anchors internal hemorrhoids weakens over the years, making prolapse more likely even without heavy straining.
Symptoms to Recognize
The most noticeable symptom is feeling tissue outside the anus, particularly during or after a bowel movement. You may also notice bright red blood on toilet paper or in the bowl, since the stretched mucosa bleeds easily. Mucus discharge is common, which can cause itching and irritation around the anal area. A feeling of incomplete evacuation, as though something is still “there” after you’ve finished, is another hallmark of prolapse.
Because prolapsed tissue is covered in mucosa rather than skin, it isn’t always painful. Many people are surprised by how little a Grade II or III prolapse hurts. Pain becomes a bigger concern when complications develop.
Strangulation and Thrombosis
Two complications can turn a prolapsed hemorrhoid into an emergency. Strangulation happens when the anal sphincter clamps down on a prolapsed hemorrhoid and cuts off its blood supply. This causes extreme pain and requires prompt medical attention. Thrombosis occurs when a blood clot forms inside the hemorrhoid, creating a hard, intensely painful lump. A thrombosed hemorrhoid isn’t dangerous on its own, but it can be excruciating and sometimes needs to be drained.
If a prolapsed hemorrhoid suddenly becomes severely painful, turns dark purple or black, or you can’t push it back in and the pain is escalating, those are signs of strangulation or thrombosis that warrant a same-day medical visit.
How It’s Diagnosed
A doctor can often identify prolapse with a visual exam, especially if you bear down during the examination. A digital rectal exam, where the doctor uses a gloved finger to feel inside the anal canal, provides additional information. When those assessments don’t give a clear picture, particularly for Grade I or early Grade II hemorrhoids that stay internal most of the time, an anoscopy may be needed. This involves inserting a short, hollow tube to examine the lining of the lower rectum directly. It’s a quick office procedure that provides a much clearer view of internal tissue.
Home and Conservative Management
For Grade I and II prolapse, and even some Grade III cases, you can manage symptoms effectively at home. Warm sitz baths (sitting in a few inches of warm water for 10 to 15 minutes) reduce swelling and ease discomfort. Over-the-counter topical treatments can relieve itching and irritation, and stool softeners help you avoid straining.
If the hemorrhoid protrudes and doesn’t retract on its own, you can gently push it back in with a clean finger. Using a bit of lubricating jelly makes this easier. The key is gentle, steady pressure rather than forcing it. If the tissue is too swollen to push back, lying down and applying a cool compress to reduce swelling first can help.
Fiber is the single most important dietary change. The recommended daily intake is 28 grams for a 2,000-calorie diet, or roughly 14 grams per 1,000 calories consumed. Most people fall well short of that. Increasing fiber gradually through fruits, vegetables, whole grains, and legumes (or a fiber supplement) softens stool and reduces the straining that caused the problem in the first place. Drinking plenty of water alongside the fiber is essential, since fiber without adequate fluid can make constipation worse.
Procedures and Surgery
When conservative measures aren’t enough, several procedures can address prolapse directly. Rubber band ligation is the most common office-based treatment for Grade I through III hemorrhoids. A small rubber band is placed around the base of the internal hemorrhoid, cutting off blood flow so the tissue shrinks and falls off within a few days. It’s done without anesthesia and causes mild to moderate discomfort for a day or two.
For more advanced prolapse, particularly Grade III and IV, surgical options become necessary. A hemorrhoidectomy, the complete removal of hemorrhoidal tissue, is the most definitive treatment. Recovery averages two to four weeks, and it can be six to eight weeks before you’re able to resume strenuous exercise or heavy physical work. It’s the most painful recovery option, but it also has the lowest recurrence rate.
Stapled hemorrhoidopexy is another surgical approach used for Grade III and IV prolapse. Instead of removing the tissue, it repositions the prolapsed hemorrhoid back into the anal canal and reduces blood flow to the area. Recovery tends to be less painful than a traditional hemorrhoidectomy, though recurrence rates are somewhat higher over time.
Preventing Recurrence
Prolapsed hemorrhoids can come back, especially if the habits that caused them don’t change. Keeping your fiber intake consistently high, staying hydrated, and avoiding prolonged sitting on the toilet are the most effective prevention strategies. When you feel the urge to have a bowel movement, go promptly rather than waiting, since delaying can lead to harder stools and more straining. Regular physical activity helps keep bowel movements regular, but avoid holding your breath during heavy lifting, which spikes abdominal pressure. Breathing out during exertion reduces that pressure significantly.