Internal hemorrhoid


  • Pathologic state cccurs when internal or external hemorrhoid plexus become engorged, prolapsed, or thrombosed
  • Bleeding is usually limited (surface of stool, on toilet tissue, at end of defecation)
    • Passage of blood clots requires evaluation for colon lesions

Risk Factors

  • Constipation and straining at stool
  • Frequent diarrhea
  • Older age
  • IBD

Clinical Features

  • Occur proximal to dentate line
  • Constant in their location: 2-, 5-, and 9-o'clock positions (when patient viewed prone)
  • Not readily palpable; best visualized through anoscope
    • May be palpable when prolapsed or thrombosed
  • Painless bleeding
    • Only painful when nonreducible, strangulation of prolapsed hemorrhoid, or thrombosis (these can lead to infection/necrosis)

Differential Diagnosis

Anorectal Disorders

Lower gastrointestinal bleeding


Internal hemorrhoid chart

Internal hemorrhoid grades
  • Luminal protrusion above dentate line
  • No prolapse
  • Painless bleeding
  • Prolapse with spontaneous reduction
  • Prolapse during straining
  • Prolapse requires manual reduction
  • Prolapse during straining
  • Prolapseā€”nonreducible
  • Can result in edema and strangulation


  • Conservative treatment
    • Indicated for mild to moderate symptomatic patients with grade 1 to grade 3 hemorrhoids
    • Stool softeners (psyllium), high-fiber diet, topical analgesics
    • Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
    • Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
    • Outpatient surgical referral
    • Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced
  • Emergent surgical consultation and intervention is indicated for:
    • Continued and severe bleeding
    • Incarceration and/or strangulation (grade 4 hemorrhoids)
    • Intractable pain


  • When prolapse occurs may develop mucous discharge and pruritus ani
    • If prolapse cannot be reduced progressive edema and strangulation may result
    • Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis


  • Generally may be discharged (unless need for surgical intervention)

See Also


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