What are Different Types of Hemorrhoids

Hemorrhoids are masses, clumps, cushions of tissue full of blood vessels that aid muscle, and elastic fibers in the anal canal. However, when the hemorrhoids guarding the anal passage become too big and bulge from the walls of anal canal especially while passing stools because of infection, which results in the vein partitions that turn out to be stretched, thin, and painful while passing bowel movements, that is when piles develop.

The abnormal swelling in the blood vessels in or around the anal canal resembling a venous cushion found in the lower rectum hampers the stool control mechanism.

Hemorrhoids manifest the symptoms when the vascular tissue becomes inflamed and swollen. Although they may bleed, itch, or cause pain, they can be treated and healed by making a few healthy lifestyle changes.

Main reasons for having hemorrhoids are:

• Low fiber diets lead to constipation and increase pressure while passing bowel, causing engorgement.
• Constant diarrhea may also cause engorgement. 
• Prolonged lavatory sitting for hours blocks the flow around the anal canal. 
• Trauma and age are also associated. 
• Some secondary pathologies like high blood pressure, liver disorders may lead to hemorrhoids. 
• Stressed & tight anal opening makes the patient push harder during defecation. 
• Pregnancy and portal hypertension also lead to hemorrhoid engorgement.

There are three types of hemorrhoids, based on their origin, which helps to determine blood supply, histology, and the possibility to cause pain. They can occur separately or in combination and one could have single hemorrhoid or have several at the same time.

1. Internal, originating in the rectum
2. Prolapsed internal hemorrhoids
3. Mixed Hemorrhoids
4. External, originating in the anus
5. Thrombosed external hemorrhoids

A: Internal Hemorrhoid

Internal hemorrhoids are located in the inside lining of the rectum along the anal canal wall and are not obvious unless they are considerably enlarged, in which case they can be felt.

• Anatomically, these are found above the dentate or pectinate line, especially the left lower anal cushion, right posterior anal cushion, and right anterior anal cushion or precisely found at 3, 7, and 11 o’clock positions.
• Symptoms are usually painless with streaks of blood in toilet pot or toilet paper, itching, and a feeling of fullness after a bowel movement. 
• Bleeding however is the primary sign which proves their presence.
• Moreover, they are usually painless due to few pain-sensing nerves in the region. 
• They are painless and often present without causing any discomfort because of the rectal lining or the mucous membrane surrounding it, rather than nerve-rich skin. 
• Sometimes internal hemorrhoids push down or stretch outwards until it bulges outside of the anus and gets prolapsed. 

B: Prolapsed Internal Hemorrhoids

Hemorrhoids prolapse when their blood vessels swell and extend from their location in the rectum through the anus due to exposed hemorrhoids leading to the trauma while passing stool, particularly hard stools associated with constipation which can cause bleeding along with mild pain.

If one is able to see or feel the moist pads of skin that are pink in texture than the surrounding area, it confirms that the internal hemorrhoids have prolapsed or protrude outside the anus.

• Mostly caused due to the presence of stool, inflammation, and constant moisture that lead to anal itchiness and occasionally the constant feeling of the need to have a bowel movement.
• Clinically these hemorrhoids occasionally hurt because the anus is dense with pain-sensing nerves. Such slipped hemorrhoids usually recede back into the rectum on their own, but fall out again with the next bowel movement. If they don’t, they can be gently pushed back into place manually.

When inner hemorrhoids swell and stick out of the anus, then prolapsed hemorrhoids occur. There are 4 grades for prolapsed hemorrhoids.

• Grade 1 – hemorrhoids are not bulging out, with painless bleeding.
• Grade 2- bulging out, but spontaneously regresses
• Grade 3 – Bulges out and needs to be returned digitally or manual reduction by the patient.
• Grade 4 – Permanently bulge or prolapsed and can’t be returned digitally.

The confinement and strangulation of the hemorrhoids might cause pain by triggering the anal sphincter complex spasm resulting in ischemia and necrosis of internal hemorrhoids, characterized by:

• Bleeding and/or prolapsed internal hemorrhoids irritating the sensitive perianal skin and perianal itching.
• This can lead to anal sphincter complex spasm and potentially external hemorrhoid thrombosis with cutaneous pain.

C: Mixed Hemorrhoid

Hemorrhoid starts off as internal and moves on as an external type of hemorrhoid. This is basically a transitioning stage.

D: External Hemorrhoids

External hemorrhoids are small soft pads under the skin just around the anal opening, the same color as of the skin. 

• Anatomically, these develop below the dentate line, which is innervated by circumferential cutaneous nervine meshwork. Hence any distention of this innervated skin due to a clot or edema results in severe pain.
• The blood clot formed due to eroded external hemorrhoids appears blue in color and causes severe pain and itching. 
• Due to the presence of pain-sensing nerves, the external hemorrhoids tend to hurt & bleed, and many times get prolapsed as they get bigger & bulge outside the anal sphincter.

E: Thrombosed External Hemorrhoids

Thrombosed hemorrhoids seem like lumps or swelling around the anus that incorporates a blood clot within the hemorrhoid tissue. They are seen when an external hemorrhoid prolapse to the outside usually while passing a stool or bowel movement. Blood clots appear in both inner and outside hemorrhoids, exhibiting the following symptoms:

• Redness and swelling around the anal area
• Intense ache and Itching while sitting
• Bluish shade across the place of hemorrhoid
• Blood clots cause an extremely painful condition

The hemorrhoidal thrombosis occurs when the surrounding skin gets scraped away and leads to bright red color bleeding that meanwhile gets developed into a clot or thromboses, characterized as a tender, circular, purplish bulging structure around the anal opening.

• Acute thrombosis triggers cutaneous pain, lasting for 7–14 days.
• In the meantime, the thrombosis resolves after certain medications and lifestyle changes leaving behind residual skin or skin tags of the distended anal skin.

While most hemorrhoids completely resolve within a week or so with lifestyle changes and ayurvedic medications, some have ongoing hemorrhoids throughout life. The importance of following a healthy diet & lifestyle regime is well portrayed by the quote, “An ounce of prevention is worth a pound of cure” as by being the custodian of the body and taking action to employ a healthy dietary regime, being hydrated, avoiding a abdominal strain, and regular exercise might help to avoid the recurrence of hemorrhoids.