Hemorrhoids: Types, Features, and Management

Hemorrhoids: Types

1. Internal hemorrhoids

   • Originate above the dentate line (from the superior rectal venous plexus).

   • Covered by columnar epithelium → not painful (no somatic innervation).

   • Symptoms: painless bright red bleeding, prolapse, mucus discharge, and pruritus.

2. External hemorrhoids

   • Originate below the dentate line (from the inferior rectal venous plexus).

   • Covered by anoderm/skin → richly innervated → painful.

   • Symptoms: acute pain, swelling, and may thra ombose (bluish perianal lump).
     

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Differentiating Internal vs. External

Feature	Internal Hemorrhoid	External Hemorrhoid
Location	Above the dentate line	Below the dentate line
Epithelium	Columnar (insensate)	Squamous/skin (sensitive)
Pain	❌ Painless	✅ Painful, esp. thrombosis
Main Symptom	Bleeding, prolapse	Perianal pain, swelling
Exam	Seen on anoscopy	Visible on inspection

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Grading of Internal Hemorrhoids (by degree of prolapse)

(Most widely used = Goligher’s classification)

• Grade I:

  • Hemorrhoids protrude into lumen but do not prolapse outside the anal canal.

  • Present with painless rectal bleeding only.

• Grade II:

  • Hemorrhoids prolapse outside anal canal during defecation but reduce spontaneously.

• Grade III:

  • Hemorrhoids prolapse during defecation or exertion and require manual reduction.

• Grade IV:

  • Hemorrhoids irreducibly prolapsed, permanently outside the anal canal.

  • May become thrombosed or strangulated.

📌 Mnemonic:

• I = In (never prolapse).

• II = Out, In (comes out but goes back in by itself).

• III = Out, Need Hand In (manual reduction needed).

• IV = Always Out (irreducible).

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Thrombosed External Hemorrhoid

• Definition: Acute clot (thrombus) formation within an external hemorrhoidal vein (below dentate line).

• Pathophysiology: Sudden venous rupture → blood clot trapped under skin → intense perianal pain.

• Clinical features:

  • Severe acute pain (esp. during sitting, coughing, defecation).

  • Tender bluish perianal nodule (subcutaneous).

  • Swelling, difficulty sitting.

  • Pain peaks in first 48–72 hrs, then gradually improves.

• Management:

  • If <72 hrs: Excision under local anesthesia (thrombectomy) → immediate pain relief.

  • If >72 hrs: Conservative (analgesics, sitz baths, stool softeners, Daflon).

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Acute vs. Chronic Hemorrhoids

• Acute Hemorrhoids

  • Sudden onset, often due to thrombosis.

  • Severe pain (esp. external).

  • Perianal swelling, tender bluish nodule.

  • Acute bleeding is possible.

  • Usually self-limited but very symptomatic.

• Chronic Hemorrhoids

  • Long-standing, recurrent symptoms.

  • Painless rectal bleeding during defecation.

  • Prolapse (grades II–IV).

  • Pruritus ani, mucus discharge, soiling.

  • Pain only if thrombosed or strangulated.
    

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Cut-off Between Acute vs. Chronic Hemorrhoids

Acute Hemorrhoids

• Definition: New, sudden event, usually due to thrombosis or strangulation of a hemorrhoidal vein.

• Time course: Symptoms develop within hours to days.

• Main hallmark: Severe pain + perianal swelling (external or prolapsed thrombosed internal).

• Course: Self-limited, resolves in days to ~2 weeks, even without surgery (though excision may speed recovery).

👉 Cut-off: Acute = Thrombosed or strangulated hemorrhoid with symptoms < 2 weeks.

Chronic Hemorrhoids

• Definition: Long-standing vascular cushion enlargement with recurrent symptoms.

• Time course: Symptoms persist or recur for weeks to months.

• Main hallmark:

  • Painless rectal bleeding during/after defecation.

  • Prolapse (graded I–IV).

  • Mucus discharge, pruritus, soiling.

  • Pain only if thrombosed (then → acute flare on chronic).

👉 Cut-off: Chronic = Recurrent or persistent symptoms > 2 weeks with structural changes (bleeding, prolapse, pruritus, mucus).

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✅ Hemorrhoids Management

1. Conservative / Medical Management

Indicated for:

• Grade I–II internal hemorrhoids.

• External hemorrhoids (non-thrombosed).

• Chronic hemorrhoids without severe prolapse.

Measures:

• Lifestyle: High-fiber diet (20–35 g/day), hydration, avoid straining, regular exercise.

• Sitz baths: 10–15 min × 2–3/day.

• Stool softeners/laxatives: Docusate, PEG.

• Medications:

  • Daflon (MPFF) – venotonic, reduces bleeding/inflammation.

  • Topical hydrocortisone, lidocaine, and witch hazel.

  • NSAIDs / acetaminophen for pain.
    

2. Office-Based / Minimally Invasive Procedures

Indicated for:

• Grade II–III internal hemorrhoids refractory to conservative therapy.

Options:

• Rubber band ligation (most effective for Grade II–III).

• Sclerotherapy (phenol injection).

• Infrared coagulation / bipolar diathermy.
  

3. Surgical Management (Hemorrhoidectomy / Stapled Hemorrhoidopexy)

Indicated for:

• Grade IV internal hemorrhoids (irreducible prolapse).

• Large Grade III hemorrhoids not responding to rubber band ligation.

• Thrombosed external hemorrhoid (within 72 hrs of onset → excision under local anesthesia).

• Recurrent bleeding with anemia.

• Mixed hemorrhoids (internal + external).

Surgical Options:

• Excisional hemorrhoidectomy (Milligan-Morgan or Ferguson) – gold standard for advanced hemorrhoids.

• Stapled hemorrhoidopexy – for circumferential prolapse.

• Thrombectomy – for acute painful thrombosed external hemorrhoids (<72 hrs).

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High-Yield

• Grade I–II → Medical/office procedures.

• Grade III → Start with rubber band ligation; surgery if refractory.

• Grade IV → Surgery definitive.

• Thrombosed external hemorrhoid → excision if <72 hrs (best pain relief).
  

In summary:

• Medical + lifestyle → Grades I–II.

• Office procedures → Grade II–III.

• Surgery → Grade IV, large/refractory Grade III, thrombosed external hemorrhoids, recurrent severe bleeding.