The first two photos (Figs. 28.1 and 28.2) are of prolapsing internal hemorrhoids. The first photo shows a hemorrhoid that is somewhat inflamed and likely bled significantly during and after defecation. The main feature of these two photos is the white tissue on the surface of the hemorrhoid. This is pseudoepitheliomatous hyperplasia, and when it is seen on internal hemorrhoids, it is a classic sign of chronic prolapse. It develops as a reaction of the anorectal epithelium to the physical trauma of repeated prolapse. It can be seen in other areas of the body subjected to chronic trauma and histologically can resemble squamous neoplasia. When it is seen in the anus, biopsy is not necessary, but in a symptomatic patient, it confirms the diagnosis of hemorrhoidal prolapse and reinforces the need for banding or even hemorrhoidectomy (depending on the patient’s symptoms and the size of the hemorrhoid). In this setting, it is not premalignant. If the hemorrhoidal prolapse is effectively treated (with banding), the pseudoepitheliomatous hyperplasia will fade away.