Second-Degree Internal Hemorrhoids Reduce Spontaneously
Internal hemorrhoids that prolapse with defecation but reduce spontaneously are classified as second-degree (Grade II) hemorrhoids. 1
Hemorrhoid Classification System
The standard grading system for internal hemorrhoids, established by Banov et al. and adopted by the American Society of Colon and Rectal Surgeons, defines four distinct grades based on prolapse behavior 1:
First-degree (Grade I): Bleed but do not prolapse beyond the anal canal 1, 2
Second-degree (Grade II): Prolapse through the anus during defecation but reduce spontaneously without manual intervention 1, 2
Third-degree (Grade III): Prolapse and require manual digital reduction to return inside the anal canal 1, 2
Fourth-degree (Grade IV): Prolapse and cannot be reduced, remaining permanently outside the anal canal; these usually include both internal and external components and may involve circumferential rectal mucosal prolapse 1, 2
Clinical Significance
The distinction between grades is critical for treatment selection. Second-degree hemorrhoids typically present with painless bright red rectal bleeding and visible tissue prolapse during bowel movements that spontaneously retracts afterward 1. These hemorrhoids respond well to office-based procedures such as rubber band ligation, which achieves symptom resolution in approximately 89% of patients, though repeated treatment may be needed in up to 20% of cases 2, 3.
Common Pitfall
Do not confuse second-degree hemorrhoids (spontaneous reduction) with third-degree hemorrhoids (requiring manual reduction), as this distinction directly determines whether office-based procedures versus more invasive surgical intervention is appropriate 1, 4.
Answer: B-2 (Second-degree)