At a glance
Internal hemorrhoids are classified into four grades based on how much they prolapse (protrude) from the anal canal. This grading system helps clinicians communicate about severity and guides treatment decisions. Understanding the grades can help you have a more informed conversation with your doctor.
This guide covers what each grade means, how they differ in symptoms and treatment, and what the grading means for you practically.
Understanding the grading system
The grading system applies specifically to internal hemorrhoids — those that originate above the dentate line inside the anal canal. External hemorrhoids are not graded using this system.
The four grades describe a spectrum from mild to severe, based on the degree of prolapse:
Grade 1: no prolapse
What it means
The hemorrhoid remains entirely inside the anal canal. It does not protrude during bowel movements.
Typical symptoms
- Bleeding — usually the main or only symptom
- Bright red blood on toilet paper or in the toilet bowl
- Often painless — internal hemorrhoids above the dentate line have limited pain sensation
- May be discovered during investigation for bleeding rather than noticed by the person
Common treatment approaches
- Conservative management: fibre, hydration, avoiding straining
- Good toilet habits
- Monitoring for any progression
- Procedures are rarely needed for grade 1 alone
Grade 2: prolapse that reduces spontaneously
What it means
The hemorrhoid protrudes from the anal canal during bowel movements but goes back in on its own afterwards.
Typical symptoms
- Bleeding — often more noticeable than grade 1
- A sensation of something protruding during bowel movements that then resolves
- Mucus discharge — as the prolapsing tissue is exposed
- Mild discomfort during bowel movements
- Itching — from mucus on the perianal skin
Common treatment approaches
- Conservative management remains the first line
- Rubber band ligation (banding) — the most commonly recommended procedure for grade 2 hemorrhoids. Done in clinic, quick, and effective for many people
- Injection sclerotherapy — an alternative in-clinic option
- Infrared coagulation — another non-surgical approach
Grade 3: prolapse that requires manual reduction
What it means
The hemorrhoid protrudes during bowel movements and does not go back in on its own — it needs to be manually pushed back (reduced).
Typical symptoms
- Visible and palpable prolapse during bowel movements
- Needing to push the tissue back in manually
- Bleeding — often more significant
- Mucus discharge and perianal moisture
- Discomfort, heaviness, or aching
- Itching and skin irritation from chronic moisture
- Potential for incontinence symptoms if the sphincter is affected
Common treatment approaches
- Conservative management to control symptoms
- Banding — can be effective for grade 3, though results may be less complete than for grade 2
- Surgical options — hemorrhoidectomy (surgical removal) or stapled hemorrhoidopexy may be discussed for grade 3 hemorrhoids that do not respond to banding
- The choice depends on symptom severity, patient preference, and surgeon recommendation
Grade 4: permanent prolapse
What it means
The hemorrhoid is permanently prolapsed — it cannot be pushed back in, or it immediately re-prolapses after reduction.
Typical symptoms
- Constant protrusion of tissue from the anus
- Persistent discomfort or pain
- Ongoing mucus discharge and moisture
- Significant hygiene challenges
- Potential for thrombosis (blood clot forming within the prolapsed hemorrhoid)
- Skin irritation and breakdown around the anus
- Significant impact on quality of life
Common treatment approaches
- Surgical treatment is usually recommended — grade 4 hemorrhoids rarely respond adequately to non-surgical approaches
- Hemorrhoidectomy — surgical excision; the most established option for grade 4
- Stapled hemorrhoidopexy — an alternative surgical approach
- Emergency surgery — may be needed if the prolapsed hemorrhoid becomes incarcerated (trapped outside) or thrombosed
- Post-operative management including stool softening and wound care
What the grades mean practically
Not a linear journey
Having grade 1 hemorrhoids does not mean they will inevitably progress to grade 4. Many people remain at the same grade for years, particularly if they manage the contributing factors.
Treatment matched to severity
The grading system helps guide treatment — more conservative approaches for lower grades, procedural or surgical approaches for higher grades. But symptoms matter as much as grade. A grade 2 hemorrhoid causing significant bleeding and disruption to daily life deserves active treatment, not just “watch and wait.”
The conversation with your clinician
Knowing about the grading system allows you to ask informed questions:
- “What grade are my hemorrhoids?”
- “What treatment options are appropriate for this grade?”
- “What is the likelihood of progression?”
- “At what point would you recommend a procedure?”
External hemorrhoids
External hemorrhoids — those that develop below the dentate line, on the outer rim of the anus — are not classified using the grading system. They are managed based on symptoms:
- Small, asymptomatic external hemorrhoids may need no treatment
- Thrombosed external hemorrhoids (containing a blood clot) cause sudden, severe pain and may benefit from drainage in the first 48 to 72 hours
- Skin tags that remain after a thrombosed hemorrhoid resolves are cosmetic rather than medically concerning