What Are Different Grades of Piles

Hemorrhoids or piles are dealt with rationally under the concept of Arsha in Ayurveda, & called mamsa-ankura meaning ‘pricking like needle’, formed by the abnormal enlargement of the anal cushions due to inflammation & forming fleshy projections that cause distortion of the blood supply channel, resulting in weakening of the supporting connective tissue. The most cardinal manifestation of hemorrhoidal disease is painless bright red coloured rectal bleeding associated with bowel movement. 

Ayurveda classifies hemorrhoids as a digestive disorder due to tridosha imbalance & also included it in ashta-mahagada or eight dreadful disease list. Varicosity at anal opening might resemble shapes such as mustard-like, pea-like, barley like plum, fig, and like so many ankuras or buds that the doshas involvement in their manifestation. 

The classification system of hemorrhoids is important to decide the approach to treatments and also to evaluate the healing effectiveness among the treatment given. The stages of the hemorrhoids are generally classified based on their location in the guda–valli (anal canal) as said in the ayurvedic context and symptoms exhibited due to the prolapse of the clumps i.e how far it reaches the anal canal. 

For feasible applied aspects, internal hemorrhoids are graded based on their appearance and degree of prolapse below the pectinate line into the anal canal known as Goligher’s classification. The grading of internal hemorrhoids are;

GRADE I / First-degree hemorrhoids:
Remains inside the rectum only.

Internal hemorrhoid bulges into the canal & remains inside the canal triggering the anal cushions to bleed due to pressure over the walls during straining.

Clinical manifestation:

• Painless bleeding: The blood streaks are usually not mixed in stool but instead coated on the outer surface of the stool. The blood engagement typically of bright red colour is seen during cleansing and wiping after a bowel movement. 
• Discomfort & itching past anal opening: Due to a persistent feeling of having bowel movements and usually by soiling of clothes, continuous itching and discomfort are observed.

GRADE II / Second-degree hemorrhoids:
Prolapse through the anus while defecating & reduce spontaneously

The anal cushions slide through the anus on straining but reduce spontaneously while pressure is applied on the rectal or anal wall area causing mild discomfort and automatically returning to their usual size after the anal cushions get relaxed.

Clinical manifestation:

• Pea-sized swelling: The size of muscle sprouts usually vary from mustard-like to a pea with prickly projections.
• Painless bleeding: Bright red colour brisk bleeding is attributed in the form of drops sometimes as splash in the pan due to the direct link of hemorrhoids with the arterio-venous blood supply link.
• Mild discomfort with irritation while wiping anal verge after defecation, due to the presence of prolapsing tissue causing significant itching and irritation around the anal opening.
• Urge to pass bowel frequently: The irresistible feeling of passing bowels frequently due to a sense that their stool pieces are still stuck at the anus verge.
• Swelling around the anal opening: Continous itching and touching the affected area due to mucus discharge and difficulty with cleaning the anus after having bowel movement results in swelling around the anal area.

GRADE III / Third-degree Hemorrhoids:
Prolapse through the anus on defecation but need manual reduction

The anal cushions droop down the anus on exertion and require manual replacement into the anal canal causing painful bleeding & soiling of clothes. They need conservative treatment to prevent them from becoming too painful or infected.

Clinical manifestation:

• Mucus discharge causing pruritus ani: The slimy mucus oozing from the anal mucosa results in soiling of the clothes and also causes an intense prickly type of itching resulting in pruritus ani.
• Painful bleeding after straining: The bleeding pattern is usually seen while excess straining or due to intense pressure applied to the anal area while sitting.
• Discomfort while in a sitting posture: Due to the presence of soft muscle clump felt outside the anus results in stretching out the overlying skin area resulting in discomfort.
• Unable to control bowel movements: Because of continuous slimy discharges & inability to resist bowel movements, the affected area turns red and sore by repeated wiping of the anus.
• Painful lump feeling around the anus with a need to push it inside the anus with fingers.

GRADE IV / Fourth-degree Hemorrhoids:
Remains persistently prolapsed

The protruded part of the lump stays out at all times and is irreducible manually also, exhibiting symptoms like pain, bleeding, clotting, hematomas, and possible strangulation if not treated.

Clinical manifestation:

• Extreme pain: The upraised level of pressure around the muscle lump results in overstretching of the lapping skin area irritating the nerves and causing extreme pain.
• Lump with a bluish tinge and smooth shiny skin present outside the anus of varying size starting from mustard-like to fig sized sprouts.
• Bleeding, when pressure is applied on anus while sitting or defecating.
• Difficulty in wiping the anus after defecation due to excoriated skin area with continuous itching and irritation.

Hemorrhoids are the most common anorectal condition which in normal anatomy acts to assist the anal opening in maintaining bowel continence. The hemorrhoidal disease is clinically diagnosed using a simple internal examination of the anal passage. There are various treatment options for more severe hemorrhoids, but they are treatable with dietary and lifestyle modifications such as high-fibre diet, hydration, laxatives or stool softeners, and avoiding the straining, and certain topical and oral ayurvedic formulations effectively. Most patients can be treated with office-based primary care with dietary advice and avoidance of the risk factors involved and certain herbal formulations.