With nearly 4 million¹ office and emergency room visits annually, hemorrhoids are the third most common outpatient gastrointestinal diagnosis in the United States. Worldwide, it's estimated that 4.4%² of the global population has symptomatic hemorrhoids.
Hemorrhoids occur when the veins in the lower part of the rectum and anal canal become swollen and irritated. This condition is characterized by rectal pain, itching, bleeding, and sometimes prolapse (hemorrhoids that protrude through the anal canal).
Internal hemorrhoids are graded from 1–4 based on the extent of prolapse and whether they can be reduced. Permanently prolapsed, meaning protruding from the anal canal and not reducible, grade 4 internal hemorrhoids are the most severe.
If you've just been diagnosed with grade 4 hemorrhoids, you may be asking what that means and how serious it is. Read on to find out.
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Hemorrhoids are the vascular cushions lining the lowest part of the rectum and the anus. They perform various functions, including protecting the sphincter, closing the anal canal when abdominal pressure increases, and sensing the difference between stool, liquid, and gas.
Due to their sensitive location, these clusters of veins are prone to a wide range of issues. The condition we know as 'hemorrhoids' develops when those veins become inflamed and distended, akin to varicose veins in the legs.
Hemorrhoids can be internal or external. Internal hemorrhoids originate higher up in the anal canal and are generally not visible on the outside. External hemorrhoids, on the other hand, develop in the lower section of the anal canal and are visible on the outside.
However, severe internal hemorrhoids can protrude through the anal canal (prolapse) and become visible. There are four classifications of internal hemorrhoids based on their degree of prolapse. These are:
Grade 1: Internal hemorrhoids that do not prolapse or protrude from the anal canal. Doctors can only see grade 1 hemorrhoids via an anoscopy or colonoscopy.
Grade 2: Internal hemorrhoids that push out through the anal canal during a bowel movement or with straining and then spontaneously return to their normal location.
Grade 3: Internal hemorrhoids that extend out of the anal canal during a bowel movement or with straining. Grade 3 hemorrhoids require manual manipulation to go back inside the anal canal.
Grade 4: Internal hemorrhoids that are irreducible and permanently prolapsed. Grade 4 can't be manually pushed back inside and require medical attention as they may strangulate.
As you can see, there are different levels of hemorrhoids. Grade 4 hemorrhoids are the most severe type of internal hemorrhoids. The symptoms of grade 4 hemorrhoids can be excruciating and annoying, and your doctor may recommend surgery for treatment.
As mentioned previously, grade 4 hemorrhoids are the most serious internal hemorrhoids. You'll likely notice a few symptoms due to these inflamed vessels. So, what are the symptoms of grade 4 hemorrhoids?
Pain and discomfort. If internal hemorrhoids become large and severe, they can be very painful — this occurs with grade 4 hemorrhoids. You may also feel some itching, stinging, or a burning sensation in the rectal area.
Rectal bleeding. Bleeding is the most common symptom of hemorrhoids. You may see blood on the toilet paper or bowl after a bowel movement. Grade 1, 2, and 3 hemorrhoids can also cause bleeding.
Permanent prolapse. Grade 4 hemorrhoids can't be reduced and are permanently prolapsed. As a result, you may feel the hemorrhoids protruding from your anal canal.
These are tell-tale signs of grade 4 hemorrhoids. Other notable symptoms of hemorrhoids may include mucus discharge and a feeling of incomplete evacuation (tenesmus). Some people may also have anal pruritus (itching) or a sense of pressure.
Doctors can usually diagnose hemorrhoids from a physical exam and medical history. Typically, external hemorrhoids are visible, especially if they form a blood clot. A physician may examine the anal canal with an anoscope for internal hemorrhoids.
Suppose the digital rectal exam finds microscopic blood in the stool or other signs of rectal bleeding. In that case, a clinician will perform a colonoscopy to rule out other possible causes of rectal bleeding, such as cancer or colorectal polyps.
Hemorrhoids can form inside the body (internal hemorrhoids) or closer to the anus (external hemorrhoids). Although it is currently unknown how exactly hemorrhoids occur, some of the risk factors include:
Chronic constipation. The most common risk factor of hemorrhoids is chronic constipation, which leads to straining during bowel movements. Too much straining causes repetitive elongation of the hemorrhoidal cushions, disrupting their supporting elements.
Prolonged sitting. Another possible association of hemorrhoids is prolonged sitting, which can be problematic for office workers. Spending too much time sitting may alter internal pressures and blood flow to and from the rectal area.
Pregnancy. Although not clearly demonstrated as the exact pathophysiology, the increased intraabdominal pressure during pregnancy, when the uterus is enlarged, is thought to contribute to the development of hemorrhoids. Other research has also identified that pregnancy is associated with alterations of the hemorrhoidal cushion, which can predispose to hemorrhoids. Although the exact prevalence is unknown, research shows that up to 85% of pregnant women develop hemorrhoids.
Aging. Another possible risk factor for hemorrhoids is aging. While people of all ages can develop hemorrhoids, they are more common in adults over 50. About 50%³ of adults over 50 have hemorrhoids.
Other possible risk factors for hemorrhoids include a low-fiber diet and diarrhea. Research² shows that being overweight can also increase the likelihood of developing hemorrhoids.
Hemorrhoids can be extremely painful and uncomfortable, but they are also treatable. Depending on the degree of prolapse, various treatment options are available for hemorrhoids. These include:
Home remedies. Over-the-counter (OTC) creams and ointments, fiber supplementation and a high-fiber diet, sitz baths, and exercise may help relieve symptoms of hemorrhoids at home. Patients can also try and limit their intake of fatty foods and alcohol to help prevent constipation. However, contrary to popular belief, studies have found no evidence that spicy food affects hemorrhoid symptoms.
Medications. Several common drugs may be used to treat hemorrhoids topically, including Lidocaine, steroid creams, astringents such as witch hazel, and creams containing zinc oxide.
Office-based procedure options. If medication proves ineffective, your doctor may recommend office-based treatment options such as electrocoagulation, infrared photocoagulation, sclerotherapy, and rubber band ligation to shrink hemorrhoids and reduce their size.
For grade 4 hemorrhoids, the first-line approach is surgical. Surgery involves completely removing prolapsed internal hemorrhoids, a procedure known as hemorrhoidectomy.
Hemorrhoids have a certain stigma attached to them. Many people are too shy to admit they have hemorrhoids, even to a doctor. But the truth is that hemorrhoids are a natural part of our anatomy, and it's not uncommon for them to become inflamed, causing rectal pain, bleeding, and other uncomfortable symptoms.
There are four levels of internal hemorrhoids. Grade 4 hemorrhoids are the most severe — when internal hemorrhoids become too severe and large, push out through the anal canal, and cannot be reduced.
There's no need to worry, even if you have grade 4 hemorrhoids. Various treatment options are available for hemorrhoids, no matter how severe.
Prevalence and associated factors of hemorrhoids among adult patients visiting the surgical outpatient department in the university of Gondar comprehensive specialized hospital, northwest Ethiopia (2021)
Definition & facts of hemorrhoids | National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
External hemorrhoid (2022)