External hemorrhoids

Swelling
\
Behavioral or genetic predisposition Vascular cushions
Inflammation Prothrombotic state Thrombosis
engorge

Activated
Pain somatic nerve
Weaken supporting tissue,
receptos
disintegrate, or deteriorate

H Itching
E
M
O Sebaceous gland increase
R Increase mucus
secretions around area of
R secretion
hemorrhoids
H
O
I Perianal
D irritation
S

Dilation of inferior Cushion epithelium

Anal cushion prolapse into rectum Painless rectal
hemorrhoidal venous erodes via damage
or anal space bleeding
plexus from compression

1st degree Bleeding without prolapse

Increase intra-abdominal pressure 2nd degree Prolapse with spontaneous Acute severe
reduction pain
Internal hemorrhoids
3rd degree Prolapse requiring manual
reduction
4th degree Irreducible Infarction and thrombosis
Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal
cushions. It happens when behavioral or genetic predisposition such as hereditary or family history of
rectal problems and increase in intra-abdominal pressure such as pregnancy, constipation, frequency of
diarrhea, sitting on defecation, lifting, cirrhosis, and chronic straining could weaken, disintegrate, or
deteriorate the supporting tissue which could lead to the prolapse of the anal cushion into the rectum or
anal space. Hemorrhoids are classified into two kinds, internal and external hemorrhoids. Internal
hemorrhoids lie inside the rectum and are found proximal to the dentate line. The dentate line divides
the upper two-thirds and lower third of the anal canal. Internal hemorrhoids are also associated with
visceral innervation.

The pressure that causes the dilatation of the inferior hemorrhoidal venous plexus could cause the
cushion epithelium to erode due to the damage from compression which results in symptoms of
painless rectal bleeding that can be seen in the stool during defecation. Internal hemorrhoids are
classified based on the degree of prolapse. 1st-degree hemorrhoids project into the anal canal and often
bleed but do not prolapse. The 2nd-degree hemorrhoids may protrude beyond the anal verge with
straining or defecating but reduce spontaneously when straining ceases or return to their resting point
by themselves. The 3rd-degree hemorrhoids protrude spontaneously or with straining and require
manual reduction or require manual effort for replacement into the anal canal. Lastly, the 4th-degree
hemorrhoids chronically prolapse and cannot be reduced; these lesions usually contain both internal
and external components and may present with acute thrombosis and infarction that causes an acute
severe type of pain.

External hemorrhoids are hemorrhoids that affect veins outside the anus which is very sensitive to pain.
This is found distal to the dentate line and is associated with somatic innervation. As the vascular
cushion engorge an inflammatory reaction occurs, involving the vascular wall and connective tissue
resulting it to become in a prothrombic state that causes thrombosis. Thrombosis in the area causes the
activation of somatic nerve receptors and causes pain in the area.

Due to vascular cushions engorgement and the dilation that originate from the inferior hemorrhoidal
venous plexus, there is now an increase in mucus secretion or fecal soiling of prolapsing hemorrhoids
which results to the sebaceous gland increase in secretion around the area of hemorrhoids that causes
the clinical manifestation of itching or perianal irritation.