A man presents with painless rectal bleeding during defecation; on examination, hemorrhoidal tissue prolapses on straining but reduces spontaneously, and his symptoms resolved after injection sclerotherapy. Which type of hemorrhoids is most likely?

Grade II Internal Hemorrhoids

This patient has grade II internal hemorrhoids. 1

Classification Rationale

The clinical presentation precisely matches the definition of second-degree internal hemorrhoids, which are characterized by:

• Painless rectal bleeding during defecation – the hallmark symptom of internal hemorrhoids 1, 2
• Hemorrhoidal tissue that prolapses during straining but reduces spontaneously – this is the defining feature that distinguishes grade II from other grades 1, 2
• Successful response to injection sclerotherapy – sclerotherapy is specifically indicated for first and second-degree internal hemorrhoids 1

Why Other Options Are Incorrect

External Hemorrhoids (Option A)

• External hemorrhoids originate below the dentate line and typically cause symptoms only when thrombosed, presenting with acute pain and a palpable perianal lump 1, 2
• This patient had painless bleeding, which is inconsistent with external hemorrhoids 2
• External hemorrhoids are not treated with injection sclerotherapy 1

Thrombosed Hemorrhoids (Option B)

• Thrombosed hemorrhoids present with acute-onset severe anal pain as the primary symptom, not painless bleeding 1, 2
• The patient's absence of pain excludes this diagnosis 2
• Thrombosed hemorrhoids require excision within 72 hours or conservative management, not sclerotherapy 1

Prolapsed Hemorrhoids (Option C)

• "Prolapsed" is not a distinct hemorrhoid type but rather describes the behavior of internal hemorrhoids 1
• If this term refers to grade III or IV hemorrhoids (which require manual reduction or are irreducible), sclerotherapy would not be appropriate – these grades require rubber band ligation or surgical hemorrhoidectomy 1, 3
• The spontaneous reduction described in this case specifically defines grade II, not higher grades 1

Internal Hemorrhoid Grading System

The American Gastroenterological Association classifies internal hemorrhoids into four grades based on prolapse behavior 1:

• Grade I: Bleed but do not prolapse 1
• Grade II: Prolapse during straining but reduce spontaneously 1 ← This patient
• Grade III: Prolapse and require manual reduction 1
• Grade IV: Prolapse and cannot be reduced 1

Treatment Confirmation

Injection sclerotherapy is specifically suitable for first and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage 1. The complete symptom resolution after sclerotherapy further confirms this was grade II internal hemorrhoid disease, as sclerotherapy achieves 70-85% short-term efficacy in this population 3.