Types and Grades of Piles: Internal, External and Prolapsed

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Understanding your piles starts with knowing exactly what type you have and how far they've progressed. Doctors classify piles by their physical location and their severity. The type tells you if the swollen veins are hidden in your rectum, causing painless bleeding, or trapped under the sensitive skin outside, causing sharp pain. For internal piles, the grade 1 to 4 measures exactly how far the lumps protrude out of your body when you use the bathroom. Knowing your exact type and grade is important because it directly decides your specific treatment plan.

Internal Vs External Piles

Grade 1 To 4 Overview

Doctors grade internal piles from 1 to 4 to see how far the swollen vein drops out of your body:
Grade 1: The veins stay completely hidden inside. You cannot feel them, but they often cause bright red, painless bleeding while having bowel movements.

Grade 2: The lump drops out when you push hard on the toilet, but goes back inside when you stand up.

Grade 3: The swollen veins drop out during the bowel movements and stay out. You have to physically push the lump back inside with your finger.

Grade 4: The lump is permanently stuck outside. It cannot be pushed inside, no matter how hard you try, and causes severe pain that makes sitting uncomfortable.

Prolapse And Thrombosis Context

While piles progress without treatment, they often lead to two highly painful complications: prolapse and thrombosis. A prolapse happens when constant straining forces a hidden internal vein to stretch and drop completely outside your body. While it sometimes pulls back in on its own, it can easily get permanently stuck. 

If blood pools inside these exposed veins, it can suddenly clot. This is called thrombosis. A thrombosed pile instantly turns into a hard, purple lump, causing severe, stabbing pain even when you sit perfectly still. Both conditions mean your internal pressure has reached a critical level, which requires immediate medical care.

How Type And Grade Are Assessed

Doctors assess piles by examining their physical location, how much the veins have stretched, and your daily symptoms. To assess the type, doctors check exactly where the swollen veins sit. If it forms under the sensitive skin outside the anus, then it is external piles. If you have bright red, painless bleeding, but cannot physically feel the lump, then it's an internal pile, hidden deep inside your rectum.

To determine the grade, the doctors check how far an internal pile drops outside when you use the bathroom and whether it goes inside on its own and stays out permanently. 

Beyond this physical exam, an Ayurvedic expert checks your pulse to know if the internal energies are out of balance and asks detailed questions about digestion, lifestyle, and food habits. This helps them to treat the root cause of the disease, not just the symptoms.

How Treatment Decisions Change

Treatment decisions for piles change accordingly on the stage/grade of the prolapse, the type, and how well the condition is responding to the initial care. There is no one-size-fits-all pill that can fit any person:

Based on Grades

In the starting stages, let's say in grades 1 and 2, only conservative management is done, which includes changing diet, using herbs, sitz baths, etc. But in severe stages, when conservative management doesn't work, active procedures are done. In Ayurveda, kshara karma is opted for, while modern medicine goes for surgeries to remove the lump.

Based on Type

Internal piles bleed easily without any pain, so treatment relies heavily on blood-purifying herbs to stop the bleeding. External piles sit outside and cause severe itching and sharp pain, requiring rich medicated herbal pastes and warm oil baths applied directly to the skin for instant physical relief.

Based on Symptoms

Your daily pain dictates the medicines. Sharp, dry pain means you need heavy oil lubrication Vata); burning and active bleeding mean we may prescribe deep cooling herbs (Pitta). If the area feels heavily swollen and constantly itchy, we focus on detoxification therapy to dry out the dampness (Kapha).

Other Health Conditions

If you are pregnant or have other medical issues, treatment changes completely. We avoid aggressive procedures and strong detoxifying medicines. Instead, we rely entirely on the safest, gentlest diet adjustments to keep your stool soft without putting any stress on you or the baby

Red Flags To Look Out For

Many warning signs must not be ignored and require urgent medical care:

• If you notice bleeding before, during, or after bowel movements.
• If discomfort from piles doesn't get resolved after weeks.
• If you have a high temperature, chills, or pus coming out of the area.
• If you have severe, unbearable anal or rectal pain.
• If you have non-stop heavy bleeding that doesn't stop.
• If your piles symptoms keep on worsening.
• If you have a hard, swollen, discolored lump near the anus.

A Quick Type Or Stage Guide

Below is a quick breakdown of what exactly this section covers:

Internal Piles 

In this section, you will learn about internal piles, including how these hidden swollen veins develop deep inside your rectum and why they cause bright red, painless bleeding during bathroom visits.

External Piles 

This section covers all about external piles, focusing on how these painful, swollen lumps under the sensitive skin ptsd the anus cause severe, constant itching.

Early Piles (Grade 1 and Grade 2) 

In this section, you will learn about early-stage piles, discovering hw minor swollen veins either stay hidden or temporarily protrude before naturally pulling back inside on their own.

Advanced Piles (Grade 3 and Grade 4) 

This section covers all about advanced piles, exploring what happens when severe lumps permanently drop outside the body, require physical pushing, and cause intense daily pain.

Prolapsed Piles 

In this section, you will learn about prolapsed piles, understanding the critical complication here: constant straining forces hidden internal veins completely out of the body, requiring immediate expert care.

References

Hemorrhoids: From basic pathophysiology to clinical management - PMC

Hemorrhoids | Piles | MedlinePlus 

Treatment of Hemorrhoids - NIDDK 

Emergency treatment of bleeding hemorrhoids in a patient taking aspirin and clopidogrel using a 1470 nm diode laser and the ELITE minimally invasive technique - PMC

Diagnosis of Hemorrhoids - NIDDK  

Management of internal hemorrhoids by Kshara karma: An educational case report - PMC 

Symptoms & Causes of Hemorrhoids - NIDDK