**Figure 2.** *Grade IV mixed hemorrhoids with thrombus in external (orange arrow) and internal (yellow arrow) components.*

## *Prolapsing Hemorrhoids DOI: http://dx.doi.org/10.5772/intechopen.104554*

Grade I: anal cushion bleeding but no prolapse. Grade II: anal cushions prolapse out of the anus during defecation, but can spontaneously return. Grade III: prolapsed anal cushions that protrude from the anus during defecation but require manual assistance to return to their original position. Grade IV: prolapsed anal cushions out the anus and cannot be reposed manually.

The American Society of Colorectal Surgery (ASCS) made a modification to Goligher grading because in Goligher the classification is based on what the patient says, but in ASCS it is based more on examination. In grades II and III, a Valsalva test should be performed, while in grade IV, this includes being able to manually reposition the prolapsed anal cushions, which will soon come back out. In grade IV, due to obstruction of venous return by the anal sphincter, often accompanied by incarceration and thrombosis under the anal mucosa or skin (**Figure 2**).
