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November 09, 2022

Author: Tanvi Lodhia, Doctor of Pharmacy


  1. What are Hemorrhoids?

Hemorrhoids are swollen, inflamed veins around the anus or lower rectum. Hemorrhoids are common in men and women and affect about 1 in 20 Americans. Nearly half of adults older than age 50 have hemorrhoids … you are not alone! Hemorrhoids can be painful and sometimes decrease your quality of life depending on your grade and type of hemorrhoid.  

There are two types of hemorrhoids:

  • Internal Hemorrhoids
  • External Hemorrhoids

hemorrhoid grades 1 2 3 4 internal external hemorrhoids prolapsed skin tag fissure

As you may guess, internal hemorrhoids develop inside the rectum, while external hemorrhoids develop around the anus. When patients develop symptoms like pain and itching, it is most often due to external hemorrhoids; these are usually more bothersome because the skin around the anus becomes agitated. Fortunately, the symptoms typically resolve within a few days for most. In contrast, Internal hemorrhoids usually go unnoticed unless you find bright red blood in the toilet bowl.

  1. How do I know which type of hemorrhoids I have? 

External hemorrhoids

Internal hemorrhoids

Anal itching & pain - Too much straining, rubbing, or cleaning around your anus may worsen the symptoms.

Bleeding – most often found in the stool, toilet, or upon wiping after a bowel movement

It may feel like tender lumps near your anus

In some cases, internal hemorrhoids can bulge outwards from the anus. This is known as a prolapse.


Internal hemorrhoids can be further classified depending on their appearance and degree of bulging or prolapse.

Prolapsed Hemorrhoids

Prolapsed hemorrhoids are usually noticed when wiping after a bowel movement. It often is described as a bump on your anus. Patients typically complain of general discomfort and the pressure to constantly use the bathroom.

Hemorrhoid Grading System Grade 1 Grade 2 Grade 3 Grade 4 Grades I Grades II Grades III Grades IIII
  • Grade 1 Hemorrhoid: non-prolapsing hemorrhoids – hemorrhoid is not seen but is bleeding
  • Grade 2 Hemorrhoid: prolapsing hemorrhoids on straining but reduces spontaneously – hemorrhoid is seen outside of the anus at times
  • Grade 3 Hemorrhoid: prolapsing hemorrhoids requiring manual reduction – hemorrhoid can manually be pushed back into the anal canal
  • Grade 4 Hemorrhoid: non-reducible prolapsing hemorrhoids, which include acutely thrombosed, incarcerated hemorrhoids – hemorrhoid that is outside the anus and can no longer be pushed back inside

Usually, internal hemorrhoids become prolapsed when there is a build-up of pressure in the canal. Depending on the grade of your hemorrhoid, your doctor may recommend treatment. Sitz baths salts for hemorrhoids can help shrink a prolapsed hemorrhoid, and hemorrhoid cream with 5% lidocaine can help dissolve some of the pain.

Thrombosed Hemorrhoids

Most thrombosed hemorrhoids occur from external hemorrhoids. They look like small lumps on the outside of your anus. The distinguishing feature is the color of the node and the sudden intense pain. It will appear to be dark and bluish. Remember – hemorrhoids are swollen, inflamed veins around the anus or lower rectum. Veins are blood vessels that carry blood back to your heart. Sometimes a blood clot can form inside the hemorrhoidal vein obstructing the passing of blood and causing painful symptoms. Your doctor may recommend preventative measures and treatment options to help with the pain and reduce the swelling, like topical pain relievers or warm water sitz baths. In severe cases, surgical excision may be needed to drain the blood clot. It is always best practice to speak to your healthcare provider before starting any new treatment.

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