What Are Prolapsed Hemorrhoids?

Prolapsed hemorrhoids are swollen veins situated inside the rectum that suddenly bulge (prolapse) out of the anus. These are different from external hemorrhoids, which occur on or around the skin of the anus, and internal hemorrhoids, which remain inside the rectum.

Prolapsed hemorrhoids aren't usually painful but can cause bleeding, itching, and discomfort, particularly while sitting or during bowel movements. Most are uncomplicated, but some severely prolapsed hemorrhoids have been known to burst, form clots, or become trapped in anal muscles and deprived of blood flow (strangulated).

How long a hemorrhoid lasts can vary from person to person. In many cases, a prolapsed hemorrhoid will shrink on its own within a few days or resolve with simple, at-home remedies. Medications or surgery may be needed for those that don't.

This article takes a closer look at the symptoms and causes of prolapsed hemorrhoids, including how they are diagnosed and treated.

Prolapsed Hemorrhoid Symptoms

Common symptoms of prolapsed hemorrhoids include:

• A painless lump: The soft, painless bump is often first discovered when wiping after a bowel movement. On examination, the bump will have protruded outside of the opening of the rectum, called the anus.
• Bleeding: Bright red blood, either on toilet paper or the stool itself, is common with prolapsed hemorrhoids. Dark red blood indicates that the bleeding is situated further up the colon (large intestine).
• Itching and irritation: Anal itchiness is common with a prolapsed hemorrhoid. The skin around the anus may also be raw and irritated.
• Mucus discharge: This whitish, pasty goo can develop as a result of rectal inflammation. You may see the mucus on stools or toilet paper after wiping.
• Foul smell: If mucus is present, it may have a bad odor.
• Incomplete evacuation: This is the sensation that your bowels are still full even after a bowel movement.
• Fecal leakage: Also known as fecal incontinence, this is caused by the protrusion of tissues outside of the anus, allowing traces of stool to leak out.

Complications of Prolapsed Hemorrhoids

A prolapsed hemorrhoid may become severely swollen, obstructing bowel movements and causing significant bleeding. If the hemorrhoid is large, the rupture of the underlying vein can cause severe bleeding and a steep drop in blood pressure, resulting in dizziness, lightheadedness, and, in rare cases, shock and death.

Other serious complications of prolapsed hemorrhoids include:

• Venous thrombosis: This is when a blood clot forms inside a hemorrhoidal vein, obstructing blood flow and causing the painful swelling of tissues. Some thrombosed hemorrhoids are the size of a grape or even larger.
• Incarceration and strangulation. This is when a hemorrhoid is trapped (incarcerated) in anal muscles and completely deprived of blood flow (strangulated). This can lead to severe pain, rapid tissue death, and gangrene.

What Causes a Prolapsed Hemorrhoid?

It is unclear why some people get hemorrhoids and others don't. Many things can contribute to the development of hemorrhoids, but they are ultimately due to the breakdown of supporting tissues in the anal canal.

If hemorrhoids are untreated, persist for a long time, or are placed under extreme vascular pressure (such as from straining or coughing), they can become prolapsed.

Risk factors for prolapsed hemorrhoids include:

• Older age
• Chronic constipation
• Chronic diarrhea
• A high-fat, low-fiber diet
• Lack of physical activity
• Obesity
• Overuse of diarrhea medications
• Pregnancy (especially after giving birth)

Prolapsed Hemorrhoid Diagnosis 

A hemorrhoid is prolapsed when it protrudes beyond the rectum. Your healthcare provider can identify them with a physical examination of the anus.

Internal hemorrhoids are classified depending on how much they protrude:

• Grade 1: These are prominent but do not protrude into the anal canal. Bleeding may occur.
• Grade 2: These protrude out of the anal canal during a bowel movement but go back inside on their own.
• Grade 3: These protrude during a bowel movement (or other forms of physical exertion) and have to be pushed back inside manually.
• Grade 4: These protrude out of the anal canal and cannot be pushed back in.

Grade 4 hemorrhoids are at high risk of strangulation and almost invariably require specialist treatment, including surgery.

Prolapsed Hemorrhoid Treatment

Most prolapsed hemorrhoids will shrink on their own but may require at-home remedies, medications, or surgery if the condition worsens or does not improve.

Self-Care Treatments

The following self-care strategies can help shrink or prevent the worsening of a prolapsed hemorrhoid:

• Ice application: Placing a cold compress on the anus for 15 minutes or so several times a day can help reduce swelling.
• Sitz bath. Soaking in a warm bath for 10 to 15 minutes can help ease discomfort.
• High-fiber diet: You can keep your stools soft by eating foods high in fiber and drinking plenty of water. Fiber supplements may also help.
• Toilet habits: Avoid straining during bowel movements. To reduce irritation, rinse the anus with a spray bottle after bowel movements and dab lightly with toilet paper or a baby wipe.
• Gentle exercise: Gentle exercises like walking regularly can help prevent constipation. Avoid weightlifting, squatting, or abdominal exercises that place stress on the anus and rectum.
• Avoid straining during bowel movements. Keep your stools soft by eating foods high in fiber and drinking plenty of water. It is recommended that you take 25-35 grams of dietary fiber daily, together with drinking eight glasses of water a day.
  

Medications

If your hemorrhoid does not get better or it comes back, there are a variety of over-the-counter (OTC) and prescription medications that may help:

• OTC ointments and creams: These include products like Preparation H and Dr. Butler's Hemorrhoid & Fissure Ointment that contain ingredients like lidocaine to numb pain and phenylephrine to shrink the enlarged veins.
• OTC stool softeners: Also known as emollient laxatives, these contain ingredients like docusate sodium that change the consistency of stools so that more moisture can be drawn in. These include brands like Colace, Correctol, Ex-Lax Stool Softener, and Fleet Sof-Lax.
• Prescription topical ointment: A topical preparation of hydrocortisone and pramoxine can help reduce the size of the hemorrhoidal vein and numb the surrounding area. Brands include Proctofoam HC, Epifoam, and Analpram-HC.

Specialist Procedures

When conservative measures fail, several specialist procedures can be used to shrink or remove a prolapsed hemorrhoid:

• Rubber band ligation: This cuts off blood flow to the hemorrhoidal vein by wrapping a band tightly around it, causing it to shrink.
• Sclerotherapy: This involves an injection of a sclerosing agent that causes the vein to scar, forcing blood to reroute through healthier veins.
• Infrared coagulation: This uses infrared light as a heat source to coagulate (clot) the vein to cut off the blood supply,

Hemorrhoid Surgeries

Surgery is a more invasive way to tie off or remove a prolapsed hemorrhoid. Surgery may be necessary if your prolapsed hemorrhoid is severe or does not respond to other treatments.

There are different types of surgery that may be used:

• Hemorrhoidectomy: This is a standard surgical procedure performed with a scalpel and stitches. Local, regional, or general anesthesia may be used. Recovery times are anywhere from two to six weeks.
• Stapled hemorrhoidectomy: This is a preferred option for prolapsed hemorrhoids in which surgical staples cut off blood flow to the hemorrhoidal vein. The surgery can often be performed under local anesthesia. Recovery times are shorter.
• Hemorrhoidal artery ligation and recto-anal repair (HAL-RAR): This is a newer procedure in which a wand-like ultrasound device is inserted into the rectum to pinpoint the blood vessels supplying the hemorrhoidal vein. These vessels are then individually tied off. Monitored anesthesia care (MAC) can be used to induce "twilight sleep."
  

Summary

A prolapsed hemorrhoid is an internal hemorrhoid that protrudes out of the rectum.

Common symptoms include a painless lump at the anus, itching or irritation, mucus discharge, and bright red rectal bleeding. Severely prolapsed hemorrhoids are at risk of painful complications like clotting of or reduced blood flow to the hemorrhoidal vein.

The treatment of prolapsed hemorrhoids depends on their severity. It may involve self-care strategies, medications, specialist procedures, or surgery.