Internal hemorrhoids. External hemorrhoids. Prolapsed hemorrhoids. Thrombosed external hemorrhoids. What’s the difference? Are they all the same thing? “I think I have hemorrhoids, but what do I need to know to make the best decision about treatment?” This article explains some of the differences and what doctors look at to evaluate how they should be treated.
Internal or External Hemorrhoids?
Doctors recognize two types of hemorrhoids: internal and external. Internal hemorrhoids occur inside the rectum, above the “dentate line.” External hemorrhoids lie outside the anal canal, below the dentate line.
The anal canal lies below the rectum and is the last place waste rests before leaving our body.
The dentate line separates the upper two-thirds of the anal canal from the lower one-third. Medical professionals use it as a demarcation line for distinguishing what type of ailment we have-that is, when a physical change takes place above this line of separation, it’s one thing. When it takes place below it, it’s a different type of ailment. In this case, hemorrhoids above the line are internal; those that form below it are external.
Prolapsed Internal Hemorrhoids
Generally, you can’t see internal hemorrhoids unless they drop below the anal canal. These hemorrhoids are referred to as “prolapsed.” They contain fewer nerves than external hemorrhoids and as a result are usually less painful. However, they do bleed when something irritates them.
Doctors categorize hemorrhoids using grade levels that increase with the severity of the piles. To evaluate the severity, they consider whether the hemorrhoids are prolapsed and the degree of bleeding. Even Grade I hemorrhoids, the least severe category, can bleed.
Doctors generally classify hemorrhoids as one of four grades:
Grade I. Hemorrhoids that bleed internally but have not prolapsed; that is, they’re not visible below the anus.
Grade II. Hemorrhoids that may drop and prolapse if the person strains to force bowel movements. However, these hemorrhoids return inside the anus on their own once the straining stops and the bowel movement ends. They’re not in a prolapsed state yet.
Grade III. Straining causes hemorrhoids to prolapse and they don’t return inside the anus by themselves when the bowel movement ends. However, when you push them back inside the anus, using your fingers, they stay.
Grade IV. Hemorrhoids protrude with straining or by themselves. In this most severe state, once outside the anus, they stay outside. You can’t push them back inside with your fingers. They’re often thrombosed, meaning engorged because of a blood clot, and very painful. These are the kind of hemorrhoids that caused Hall of Famer George Brett, one of the most durable players in baseball history, to leave the second game of the 1980 World Series during the 6th inning. The pain can be excruciating.
Thrombosed External Hemorrhoids
If you have thrombosed external hemorrhoids, it hurts to sit, stand, and move your bowels. Unlike internal hemorrhoids, external hemorrhoids are covered by skin. If you have a painful skin-covered lump in your anal area, suspect an external hemorrhoid. This type tends to be more painful because it includes more nerve endings than internal hemorrhoids. These inflamed nerve endings also lead to itching. When external hemorrhoids develop blood clots, they’re referred to as “thrombosed,” or in a state of thrombosis.
These blood clots seem to form without notice. Doctors have no clear explanation for why this happens. However, they do believe that thrombosed external hemorrhoids are probably traceable to a particular event in our lives. This might be something as physically straining as giving birth or as passive, yet straining, as sitting for long stretches, as when driving cross-country. One study found that traumatic delivery appears to be associated with thrombosed external hemorrhoids.
One of the best ways to tell whether you have a thrombosed external hemorrhoid is the color. Because they are the result of a blood clot, they take on an unmistakable bluish, purplish, or dark red color just beneath the skin.
These are some of the differences in the types of hemorrhoids people experience. Unfortunately, you can have internal and external hemorrhoids, internal hemorrhoids that have prolapsed, and thrombosed external hemorrhoids all at the same time.