How Are Hemorrhoids Classified?
Hemorrhoids Classified can be divided into internal, external, or mixed type based on the dentate line. The internal hemorrhoid is covered by the transitional epithelium (or the columnar epithelium), whereas the external hemorrhoid is covered by the squamous epithelium. A skin tag can be a result of a thrombosed hemorrhoid, or it can be a complication of an inflammatory bowel disease that has nothing to do with hemorrhoids. More than 80 % of hemorrhoids are internal, approximately 5 % are purely external, and the rest are mixed. (See Thrombosed external hemorrhoid)
Traditionally, hemorrhoids are classified on their relationship to the dentate line as internal if the area involved originates proximal to the dentate line and external if the affected area originates distal to the dentate line. However, it is quite common for patients to present with a mixed picture, with involvements of internal and external elements.
The distinction is somewhat arbitrary but does have relevance to treatment. Internal hemorrhoids involve the mucosa of the upper anal canal and lower rectum, which are devoid
of somatic nerve endings, whereas the outside element is richly innervated with somatic nerve endings, which limits treatment options in the outpatient clinic. Internal hemorrhoids are further classified by degree. (See Internal hemorrhoids symptoms)
The distinction between different levels of hemorrhoid is subjective and, while useful for comparing the results of different treatment options, has less relevance when selecting the most appropriate hemorrhoid treatment, where hemorrhoid symptoms patterns are significant. It is for this reason that other hemorrhoid classifications have been proposed that take this into account. (See Symptoms of hemorrhoids)
Classification of internal hemorrhoids
Internal hemorrhoids can be divided from first to fourth degree depending on the severity of their prolapse
- First degree: The state of venous engorgement during the bowel movement that does not protrude out of the anus but may bleed sometimes.
- Second degree: hemorrhoid that prolapses out of the anus during the bowel movement but goes back inside spontaneously into the anal canal after defecation.
- Third degree: Hemorrhoidal tissue protrudes external anal canal and requires manual reduction.: Third-degree hemorrhoids can be divided into third grade A and third degree B.
-Third level A: Hemorrhoid prolapses on defecation only and is reduced with manual reduction.
–Third Grade B: Prolapse of hemorrhoid occurs not only during the bowel movement but also on usual time, which must be pushed back in manually.
- Fourth degree: hemorrhoid protrudes from the anal canal all the time and is irreducible.
The pitfalls of this classification are that the third degree of hemorrhoid is sometimes harder than that of the fourth degree to operate, and some scholars say that this is not a helpful classification for hemorrhoid surgery. Therefore, I suggest that it should be reclassified according to the length of the prolapse measured after anesthesia during surgery.
Hemorrhoids with mucosal prolapse are also thought to be the stage before rectal prolapse. Hemorrhoid and rectal prolapse are not two different diseases; hemorrhoid seems to be a prolapse where Treitz’s ligament is destroyed, whereas the rectal prolapse appears to be caused by the weakness of the pelvic floor.
Goligher classification of hemorrhoids
Since it is hard to classify the hemorrhoids after checking the length of prolapse at an office, there is no choice but to use the Goligher classification.(See Prolapsed hemorrhoid)
The Goligher classification only considers the status of prolapse, omitting symptoms such as anal discomfort, incontinence, or the skin conditions. Another method of classification
according to the anatomical standardization is suggested.
Hemorrhoid can be classified into the first hemorrhoid ( hemorrhoid that occurs at the anal cushion), secondary hemorrhoid ( hemorrhoid that occurs between the anal cushions), and circumferential hemorrhoid. The degree of prolapse can also be classified into “no prolapse, prolapse distal to the dentate line on rest, distal to the dentate line on straining, prolapse visible at the anal verge on rest, and visible at the anal verge on straining.” The condition of the anal verge (skin tag, congestion of external hemorrhoid, etc.), anal pressure, and severity of the perineal descent also needs to be described
- The 1st degree: internal hemorrhoid which does not prolapse out of an anus.
- The 2nd degree: hemorrhoid protrudes during defecation with automatic reduction.
- The 3rd degree: hemorrhoid protrudes with manual reduction.
- The 4th degree: hemorrhoid which is irreducible into an anus.
Graham Stewart divided hemorrhoids into vascular and mucosal forms. Vascular hemorrhoids frequently occur among young and muscular people. Even without straining, engorgement
in the anal cushion can be easily formed. In an inspection, a large lump of hemorrhoid can be found, and even minor trauma can cause bleeding. However, it rarely protrudes out of the
Mucosal hemorrhoids are found more often in women than men and occur more frequently among older and thinner person. The main symptom is the prolapse of hemorrhoid, composed of vascular cushion and stretched rectal mucosa. Sometimes, these two kinds of hemorrhoids are said to appear in mixed type, regardless of sex or age. (See Home remedies for hemorrhoids)