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First degree: the hemorrhoids remain inside at all times. Second degree: the hemorrhoids extend out of the rectum during a bowel movement but return on their own. Third degree: the hemorrhoids extend out during a bowel movement but can be pushed back inside. Fourth degree: the hemorrhoid is always outside.
Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment of all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation.