the Differences Between Internal Hemorrhoids and Anal Papilla Hypertrophy

Inquiry Consultation

Dear Dr.
Chang,
In recent years, I have noticed that occasionally when I exert myself during bowel movements, a piece of tissue protrudes from my anus; after I finish, it retracts back inside.
After researching online, I initially thought it was stage II internal hemorrhoids (defined as tissue that protrudes during straining and retracts after bowel movements).
Recently, I came across a similar condition called anal papilla hypertrophy (also known as anal papilloma), which also features a piece of tissue protruding during bowel movements and retracting afterward.
Today, while showering, I squatted down to relax and allowed the tissue to protrude slightly, then I touched it with my finger to feel its shape and size.
However, it felt like a soft mass, and I couldn't discern a specific shape, making it difficult to determine whether it is internal hemorrhoids or anal papilla hypertrophy (anal papilloma).
Most online information focuses on internal and external hemorrhoids, while there is very little consistent information regarding anal papilla hypertrophy, which leaves me confused.
Therefore, I would like to ask Dr.
Chang the following questions:
Q1.
Given that both conditions feature tissue protruding from the anus during bowel movements and retracting afterward, how can one distinguish between internal hemorrhoids and anal papilla hypertrophy (anal papilloma)?
Q2.
Once anal papilla hypertrophy (anal papilloma) forms, is there a possibility that it can shrink on its own (for example, through medication or dietary adjustments), or does it only continue to grow once it has developed?
Q3.
Some online medical articles state that anal papilla hypertrophy (anal papilloma) is a benign tumor and does not undergo malignant transformation; however, others suggest that if it persists in the body for a long time, there is a tendency for malignant transformation, thus recommending surgical removal upon discovery.
In your opinion, which of these statements is correct?
Thank you, Dr.
Chang.

Axiang, 40~49 year old female. Ask Date: 2022/06/29

Dr. Zhang Shuhao reply Surgery

1.
The difference between internal hemorrhoids and anal papillae lies in the fact that hemorrhoids contain a rich supply of blood vessels, which can enlarge due to poor blood circulation or inflammatory stimuli.
Anal papillae are proliferations of skin and soft tissue that usually occur after injury; they feel slightly firmer and more prominent than hemorrhoids and do not become congested or swollen.
2.
Once anal papillae form, they do not disappear on their own, but they also do not undergo significant changes and rarely cause symptoms, so no special treatment is necessary.
3.
Simple anal papillae do not undergo malignant transformation; however, if there are other lesions with a similar appearance, such as HPV infection or adenomas, there is indeed a risk of carcinogenesis with prolonged presence.
These conditions can be difficult to distinguish on your own, so if there are concerns, it is advisable to consult a colorectal specialist for examination.

Reply Date: 2022/06/29

More Info

Understanding the differences between internal hemorrhoids and anal papilla hypertrophy (also known as anal papillae or anal tags) is crucial for proper diagnosis and management of anal conditions. Both conditions can present similarly, leading to confusion, especially for patients experiencing symptoms such as protrusion of tissue during bowel movements. Here’s a detailed breakdown of the two conditions, their characteristics, and answers to your specific questions.

Internal Hemorrhoids
Internal hemorrhoids are swollen veins located inside the rectum. They are classified into four grades based on their severity:
- Grade I: Not visible outside the anal canal.

- Grade II: Prolapse during straining but reduce spontaneously.

- Grade III: Prolapse during straining and require manual reduction.

- Grade IV: Prolapsed and cannot be reduced.

Symptoms of internal hemorrhoids can include painless rectal bleeding, discomfort during bowel movements, and the sensation of a lump or mass. The protruding tissue you describe, which retracts after a bowel movement, aligns with the characteristics of Grade II internal hemorrhoids.

Anal Papilla Hypertrophy
Anal papillae are small, soft tissue growths that can occur at the anal margin. They are often mistaken for hemorrhoids due to their similar presentation. Anal papilla hypertrophy can occur as a result of chronic irritation, inflammation, or trauma to the anal area. Unlike hemorrhoids, anal papillae are not associated with bleeding unless they become irritated or inflamed.

Key Differences
1. Location and Structure: Internal hemorrhoids are located within the rectum and are vascular structures, while anal papillae are soft tissue growths at the anal verge.

2. Symptoms: Internal hemorrhoids typically cause bleeding and discomfort during bowel movements, while anal papillae may not cause symptoms unless they become inflamed.

3. Prolapse: Both conditions can present as protruding tissue during bowel movements, but the nature of the tissue differs. Hemorrhoids may bleed, while anal papillae usually do not unless irritated.

Answers to Your Questions
Q1: How to differentiate between internal hemorrhoids and anal papilla hypertrophy?
To differentiate between the two, a thorough examination by a healthcare professional is essential. A digital rectal exam or anoscopy can help visualize the internal structures. Internal hemorrhoids will typically be more vascular and may bleed, while anal papillae will feel softer and may not exhibit bleeding unless inflamed.

Q2: Can anal papilla hypertrophy shrink on its own?
Anal papillae may not shrink significantly once formed. However, conservative measures such as dietary changes (increasing fiber intake to prevent straining), topical treatments, or managing underlying conditions may help reduce irritation and inflammation, potentially leading to a decrease in size. Nevertheless, they often persist unless surgically removed.

Q3: Is anal papilla hypertrophy benign or does it have a risk of malignancy?
Anal papilla hypertrophy is generally considered a benign condition and is not known to undergo malignant transformation. However, if a growth changes in appearance, size, or becomes symptomatic, it should be evaluated by a healthcare professional to rule out other conditions, including anal cancer. Regular monitoring and, if necessary, surgical removal are recommended for symptomatic or bothersome anal papillae.

Conclusion
In summary, while both internal hemorrhoids and anal papilla hypertrophy can present with similar symptoms, they are distinct conditions with different management strategies. If you are experiencing discomfort or have concerns about the protruding tissue, it is advisable to consult a healthcare provider for an accurate diagnosis and appropriate treatment options. Early intervention can help alleviate symptoms and prevent complications.

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