Hemorrhoid Grades Explained: Grade I, II, III & IV Hemorrhoids

Hemorrhoid Grades Explained: Understanding Grade I, II, III & IV Hemorrhoids

Not all hemorrhoids are the same.

Some internal hemorrhoids may cause occasional bleeding without coming out of the anus, while others can prolapse during bowel movements and may need to be pushed back inside. In more advanced cases, the prolapsed tissue may remain outside and cannot be manually reduced.

This is where the hemorrhoid grading system becomes important.

Healthcare professionals commonly classify internal hemorrhoids into four grades—Grade I, Grade II, Grade III and Grade IV—based primarily on whether the hemorrhoid prolapses and whether it returns inside the anus on its own or requires manual reduction.

Understanding these grades can help patients understand medical terminology, recognize why treatments may differ, and know when a professional evaluation may be appropriate.

However, hemorrhoid grade should not be determined solely from symptoms found online. A healthcare professional may need to examine the anus and rectum to determine whether hemorrhoids are present and how advanced they are.

Medical Disclaimer: This article is for general educational purposes and is not a substitute for professional medical diagnosis or treatment. Rectal bleeding, anal pain, or tissue protruding from the anus can have causes other than hemorrhoids. If symptoms are persistent, severe, recurrent, or unexplained, seek evaluation from a qualified healthcare professional.

What Are Hemorrhoids?

Hemorrhoids, also called piles, are swollen and inflamed veins around the anus or in the lower rectum. They are generally categorized as internal hemorrhoids or external hemorrhoids.

Internal Hemorrhoids

Internal hemorrhoids develop inside the anus or lower rectum.

They can cause:

•  Bright-red rectal bleeding

•  Prolapse through the anal opening

•  Irritation

•  Mucus or moisture

•  Difficulty keeping the area clean

•  Discomfort associated with prolapse

Internal hemorrhoids that have not prolapsed are often painless.

External Hemorrhoids

External hemorrhoids form underneath the skin around the anus.

They can cause:

•  Pain

•  Tenderness

•  Itching

•  Swelling

•  A lump around the anus

An external hemorrhoid can also develop a blood clot, known as a thrombosed external hemorrhoid.

Important Distinction:

The Grade I–IV system is primarily used to classify internal hemorrhoids based on prolapse.

External hemorrhoids are not normally described as Grade I, II, III or IV using this same system.

What Does "Hemorrhoid Grade" Mean?

The grade describes the degree of prolapse of an internal hemorrhoid.

In simple terms, doctors look at what happens to the hemorrhoid during a bowel movement or straining:

This classification is based primarily on prolapse behavior rather than simply how much pain or bleeding a person experiences.

This is important because a higher grade does not necessarily mean more pain.

For example, internal hemorrhoids can bleed without causing significant pain, while an external hemorrhoid can be extremely painful even though the internal grading system does not apply to it.

How Are Internal Hemorrhoids Graded?

The four-grade classification can be summarized as follows:

Grade I

The hemorrhoid remains inside the anal canal and does not prolapse.

Grade II

The hemorrhoid comes down through the anus during bowel movements or straining but returns inside on its own.

Grade III

The hemorrhoid prolapses and does not return automatically. It can be manually pushed back inside.

Grade IV

The hemorrhoid remains prolapsed and cannot be manually reduced.

This classification is commonly used when discussing internal hemorrhoid severity and treatment options.

Grade I Hemorrhoids

What Are Grade I Hemorrhoids?

Grade I hemorrhoids are internal hemorrhoids that do not prolapse outside the anus.

They remain inside the anal canal but can still produce symptoms.

Possible symptoms include:

•  Bright-red rectal bleeding

•  Irritation

•  Itching

•  Mild discomfort

•  A feeling of incomplete bowel emptying in some cases

Bleeding is one of the characteristic symptoms associated with internal hemorrhoids.

Because Grade I hemorrhoids do not prolapse, a person may not know that they have them unless symptoms lead to an examination.

What Causes Grade I Hemorrhoids?

Factors associated with hemorrhoids include:

•  Straining during bowel movements

•  Constipation

•  Chronic diarrhea

•  Low dietary fiber

•  Prolonged toilet sitting

•  Pregnancy

•  Aging

•  Frequent heavy lifting

These factors can contribute to increased pressure and weakening of supporting tissues around the anus and rectum.

How Are Grade I Hemorrhoids Treated?

Treatment often begins conservatively.

A healthcare professional may recommend:

vIncreasing dietary fiber

•  Drinking adequate fluids

•  Avoiding straining

•  Reducing prolonged toilet sitting

•  Treating constipation

•  Improving bowel habits

•  Using appropriate symptom-relief treatments

Dietary and behavioral changes are considered first-line management for symptomatic hemorrhoidal disease.

If symptoms continue despite conservative management, a healthcare professional may consider an office-based treatment depending on the individual situation.

Grade II Hemorrhoids

What Are Grade II Hemorrhoids?

Grade II hemorrhoids prolapse through the anus during bowel movements or straining but return inside on their own.

This is the key difference between Grade I and Grade II.

Grade I:

Stays inside.

Grade II:

Comes out during bowel movements but goes back inside without manual assistance.

The prolapse may be temporary and may occur primarily when straining.

Symptoms of Grade II Hemorrhoids

Possible symptoms include:

•  Rectal bleeding

•  Tissue protruding during bowel movements

•  Irritation

•  Itching

•  Moisture or mucus

•  Difficulty with hygiene

•  Discomfort associated with prolapse

Internal hemorrhoids may not be painful unless they prolapse or another complication is present.

How Are Grade II Hemorrhoids Treated?

Treatment may begin with conservative measures such as:

•  Fiber

•  Adequate fluid intake

•  Improved bowel habits

•  Avoiding straining

•  Managing constipation

If symptoms persist, office-based procedures may be considered.

The American Society of Colon and Rectal Surgeons' 2024 clinical practice guideline states that most patients with symptomatic Grade I or Grade II hemorrhoids, and selected Grade III cases that do not respond to conservative treatment, can be effectively treated with office-based procedures.

Possible procedures include:

•  Rubber band ligation

•  Sclerotherapy

•  Infrared coagulation

•  Electrocoagulation

The specific treatment depends on the patient's symptoms and clinical findings.

Grade III Hemorrhoids

What Are Grade III Hemorrhoids?

Grade III hemorrhoids prolapse outside the anus and require manual reduction.

In other words, the hemorrhoid comes out during bowel movements or straining but does not return inside by itself.

The patient may need to gently push the tissue back into the anus.

This manual reduction requirement is what separates Grade III from Grade II.

Symptoms of Grade III Hemorrhoids

Possible symptoms include:

•  Rectal bleeding

•  Prolapse during bowel movements

•  Tissue that remains outside after bowel movements

•  Need to manually push the tissue back

•  Irritation

•  Itching

•  Mucus or moisture

•  Difficulty cleaning after bowel movements

•  Discomfort

Prolapsed internal hemorrhoids can cause symptoms that are different from those of non-prolapsed hemorrhoids.

Can Grade III Hemorrhoids Be Treated Without Surgery?

Sometimes.

Treatment depends on the individual's symptoms, hemorrhoid characteristics, and response to conservative care.

The 2024 ASCRS guideline notes that selected Grade III hemorrhoids that remain symptomatic despite conservative treatment may be treated with office-based procedures, with rubber band ligation identified as an effective office treatment.

However, not every Grade III hemorrhoid is appropriate for office treatment.

Some patients with more advanced or combined internal and external disease may require a surgical approach.

Grade IV Hemorrhoids

What Are Grade IV Hemorrhoids?

Grade IV hemorrhoids are internal hemorrhoids that remain prolapsed and cannot be manually pushed back inside.

This is the most advanced category in the standard four-grade internal hemorrhoid classification.

The defining feature is irreducible prolapse.

Symptoms of Grade IV Hemorrhoids

Possible symptoms can include:

•  Persistent tissue outside the anus

•  Bleeding

•  Irritation

•  Mucus discharge

•  Difficulty with hygiene

•  Swelling

•  Discomfort or pain

•  Recurrent inflammation

Symptoms vary between individuals.

Grade IV hemorrhoids can also be associated with more complex internal and external hemorrhoidal disease.

How Are Grade IV Hemorrhoids Treated?

Treatment depends on the individual's condition.

Conservative measures may still be useful for bowel management and symptom control, but advanced prolapsing hemorrhoids often require specialist evaluation.

The ASCRS guideline states that excisional hemorrhoidectomy should typically be offered to selected patients with symptomatic combined internal and external hemorrhoids, including Grades III–IV.

This does not mean every person with a Grade IV hemorrhoid automatically requires the same procedure.

A colorectal specialist can determine the appropriate treatment after examination.

Grade I vs. Grade II vs. Grade III vs. Grade IV Hemorrhoids

The easiest way to understand the grades is to focus on prolapse and reduction.

The four grades describe internal hemorrhoid prolapse and are not simply a ranking of pain severity.

An Easy Way to Remember:

Grade I = Inside

Grade II = Out, then back in

Grade III = Out, push back in

Grade IV = Out, cannot push back in

Hemorrhoid Symptoms by Grade

Symptoms can overlap between grades, so symptoms alone cannot reliably determine a person's grade.

It is important not to assume that a particular symptom automatically indicates a particular grade.

Does a Higher Hemorrhoid Grade Mean More Pain?

Not necessarily.

The grading system is primarily based on prolapse behavior, not a pain scale.

Internal hemorrhoids can cause bright-red bleeding while producing little or no pain, particularly when they have not prolapsed.

Pain can be more prominent when:

•  An internal hemorrhoid becomes prolapsed

•  Tissue becomes irritated

•  An external hemorrhoid develops a blood clot

•  Another anorectal condition is present

Therefore:

Hemorrhoid grade and hemorrhoid pain are not the same measurement.

Someone with a lower-grade internal hemorrhoid may experience significant symptoms, while another person with a more advanced hemorrhoid may report relatively little pain.

What Causes Hemorrhoids to Progress?

Not every hemorrhoid progresses from Grade I to Grade IV.

However, factors associated with hemorrhoids can contribute to symptoms and recurrence.

These include:

•  Chronic Constipation

Hard stools can increase straining during bowel movements.

•  Straining

Repeatedly pushing during bowel movements can increase pressure in the anorectal area.

•  Prolonged Toilet Sitting

Spending excessive time on the toilet can contribute to hemorrhoid problems.

•  Low-Fiber Diet

Insufficient dietary fiber can contribute to constipation and harder stools.

•  Chronic Diarrhea

Frequent bowel movements and irritation can also contribute to anorectal symptoms.

•  Pregnancy

Pregnancy can increase pressure in the pelvic and rectal veins.

•  Aging

The supporting tissues around the anus and rectum can weaken with age.

Can Grade I Hemorrhoids Become Grade II?

They can become more symptomatic or develop prolapse, but hemorrhoids do not necessarily progress through every grade in a predictable sequence.

A person with hemorrhoids may have symptoms that change over time, and different hemorrhoidal cushions can behave differently.

Therefore, the grading system describes the hemorrhoid at the time of evaluation rather than predicting exactly what will happen in the future.

Can Grade II Hemorrhoids Become Grade III?

Hemorrhoid prolapse can become more persistent over time in some people.

For example, a hemorrhoid that previously returned inside automatically may eventually require manual reduction.

However, this is not inevitable.

Managing contributing factors such as constipation and straining may help reduce symptoms and recurrence. NIDDK recommends adequate fiber, appropriate fluid intake, avoiding straining, and avoiding prolonged toilet sitting as part of hemorrhoid prevention and treatment.

Grade III vs. Grade IV Hemorrhoids: What's the Difference?

This is one of the most common points of confusion.

The distinction is simple:

Grade III

The hemorrhoid comes outside the anus but can be pushed back inside manually.

Grade IV

The hemorrhoid remains outside and cannot be pushed back inside.

The distinction is based on reducibility, not simply size or pain.

How Are Hemorrhoids Diagnosed?

You generally cannot determine your hemorrhoid grade reliably at home.

A healthcare professional may use:

✔  Medical History

Your provider may ask about:

•  Bleeding

•  Pain

•  Bowel movements

•  Constipation

•  Straining

•  Prolapse

•  Whether tissue returns inside automatically

•  Whether you need to push it back

✔  Physical Examination

The provider may inspect the area around the anus for swelling, prolapse, external hemorrhoids, skin irritation, or other abnormalities.

✔  Digital Rectal Examination

A gloved, lubricated finger may be used to evaluate the rectum and surrounding structures.

✔  Anoscopy

An anoscope can allow the healthcare professional to look inside the anal canal and lower rectum for internal hemorrhoids and other abnormalities.

Additional tests may be considered when symptoms suggest another gastrointestinal condition or when colorectal cancer screening or evaluation is appropriate.

Why Should You Not Diagnose Your Hemorrhoid Grade Yourself?

A lump or tissue coming out of the anus does not automatically mean that you have a Grade III or Grade IV hemorrhoid.

Other conditions can produce similar symptoms.

For example, rectal prolapse can also cause tissue to protrude through the anus, and distinguishing it from hemorrhoidal prolapse may require medical examination.

Rectal bleeding can also have causes other than hemorrhoids, including diseases affecting the colon or rectum.

For this reason, persistent bleeding or new anorectal symptoms should be evaluated rather than automatically attributed to hemorrhoids.

Does Hemorrhoid Grade Determine Treatment?

Grade is an important factor, but it is not the only factor.

Treatment decisions may also consider:

•  Severity of symptoms

•  Frequency of bleeding

•  Degree of prolapse

•  Internal vs. external disease

•  Constipation or diarrhea

•  Previous treatments

•  Patient preferences

•  Overall health

•  Presence of combined internal and external hemorrhoids

The ASCRS guideline identifies dietary and behavioral modifications as first-line therapy for symptomatic hemorrhoidal disease. It also notes that most symptomatic Grade I and II hemorrhoids and selected Grade III hemorrhoids refractory to conservative treatment can be treated with office-based procedures.

Treatment Options for Grade I Hemorrhoids

Because Grade I hemorrhoids do not prolapse, treatment commonly begins with conservative measures.

These can include:

•  Increasing dietary fiber

•  Fiber supplements when appropriate

•  Adequate fluid intake

•  Avoiding straining

•  Limiting prolonged toilet sitting

•  Managing constipation

•  Appropriate topical symptom relief

NIDDK lists dietary changes, fiber, stool-softening strategies, adequate fluids, avoiding straining, and warm baths among home treatment approaches.

If symptoms continue, an office-based procedure may be considered depending on the clinical situation.

Treatment Options for Grade II Hemorrhoids

Grade II hemorrhoids may also initially be managed conservatively.

If symptoms persist, office-based procedures can be considered.

Potential options include:

•  Rubber band ligation

•  Sclerotherapy

•  Infrared photocoagulation

•  Electrocoagulation

Rubber band ligation is commonly used for bleeding or prolapsing internal hemorrhoids, and ASCRS identifies banding as an effective office-based treatment.

Treatment Options for Grade III Hemorrhoids

Grade III hemorrhoids require a more individualized approach.

Depending on the specific case, options may include:

•  Conservative Treatment

Dietary and bowel-habit changes may still be recommended.

•  Office-Based Procedures

Selected Grade III hemorrhoids may respond to procedures such as rubber band ligation.

•  Surgical Treatment

Surgery may be considered when hemorrhoids are advanced, symptomatic, recurrent, or not adequately controlled with less invasive treatment.

The appropriate treatment depends on the patient's individual anatomy and symptoms.

Treatment Options for Grade IV Hemorrhoids

Grade IV hemorrhoids are persistently prolapsed and cannot be manually reduced.

Because of this, they often require more advanced medical evaluation.

Treatment may involve surgery, particularly when there is symptomatic combined internal and external disease.

ASCRS recommends considering excisional hemorrhoidectomy for selected patients with symptomatic combined internal and external hemorrhoids, including Grades III and IV.

However, treatment decisions should be made after a professional examination.

Do Higher-Grade Hemorrhoids Always Need Surgery?

No single rule applies to every patient.

Grade is one part of treatment planning.

According to the 2024 ASCRS guideline, selected Grade III hemorrhoids may be treated with office-based procedures, while symptomatic combined internal and external Grade III–IV disease may be treated with excisional hemorrhoidectomy.

The important distinction is between:

Grade classification

and

individual treatment recommendation

The first describes the hemorrhoid's prolapse behavior.

The second requires a clinical assessment.

Can Hemorrhoids Be Treated Without Surgery?

Yes, depending on the grade and individual condition.

Conservative treatment may include:

•  Fiber

•  Hydration

•  Bowel-habit changes

•  Avoiding straining

•  Symptom-relief medications

•  Warm baths

Selected internal hemorrhoids can also be treated with office-based minimally invasive procedures.

These include:

•  Rubber band ligation

•  Sclerotherapy

•  Infrared photocoagulation

•  Electrocoagulation

NIDDK describes these as office-based treatment options for internal hemorrhoids.

For more advanced disease, surgery may be appropriate.

When Should You See a Doctor?

You should consider professional evaluation if you have:

•  Rectal bleeding

•  Persistent hemorrhoid symptoms

•  A new lump around the anus

•  Tissue protruding from the anus

•  Tissue that needs to be manually pushed back inside

•  Tissue that cannot be pushed back inside

•  Severe or persistent anal pain

•  Recurrent symptoms despite home treatment

NIDDK recommends seeking medical care for rectal bleeding or symptoms that remain after about one week of at-home treatment.

Seek Urgent Medical Care for Severe Symptoms

Severe anal pain accompanied by rectal bleeding—particularly if abdominal pain, diarrhea, or fever is also present—requires prompt medical attention.

What If Tissue Cannot Be Pushed Back Inside?

A hemorrhoid that remains outside and cannot be reduced corresponds to the defining feature of a Grade IV internal hemorrhoid, but not every mass outside the anus is necessarily a Grade IV hemorrhoid.

Because rectal prolapse and other anorectal conditions can appear similar, professional assessment is important.

If there is severe pain, heavy bleeding, fever, or other concerning symptoms, seek medical attention promptly.

How Can You Reduce the Risk of Hemorrhoid Problems?

Regardless of hemorrhoid grade, healthy bowel habits can play an important role in management.

✔  Eat Enough Fiber

Fiber can help soften stool and reduce the need to strain.

✔  Drink Adequate Fluids

Adequate fluid intake can support normal stool consistency.

✔  Avoid Straining

Do not repeatedly force bowel movements.

✔  Avoid Prolonged Toilet Sitting

Limit unnecessary time spent sitting on the toilet.

✔  Address Constipation

Persistent constipation can increase straining and should be appropriately managed.

✔  Address Chronic Diarrhea

Frequent loose stools can also contribute to anal irritation.

These measures are consistent with first-line dietary and behavioral recommendations for symptomatic hemorrhoidal disease.

Hemorrhoid Grades at a Glance

Here is the simplest summary to remember:

Grade I = stays inside

Grade II = comes out and goes back in

Grade III = comes out and needs to be pushed back

Grade IV = comes out and cannot be pushed back

Frequently Asked Questions (FAQ's):

Q. What are the four grades of hemorrhoids?

The four grades of internal hemorrhoids are based primarily on prolapse. Grade I hemorrhoids do not prolapse, Grade II prolapse but return spontaneously, Grade III prolapse and require manual reduction, and Grade IV remain prolapsed and cannot be manually reduced.

Q. What is a Grade I hemorrhoid?

A Grade I hemorrhoid is an internal hemorrhoid that remains inside the anal canal and does not prolapse through the anus.

Q. What is a Grade II hemorrhoid?

A Grade II hemorrhoid prolapses through the anus during bowel movements or straining but returns inside on its own.

Q. What is a Grade III hemorrhoid?

A Grade III hemorrhoid prolapses and does not return inside automatically. It can be manually pushed back into the anus.

Q. What is a Grade IV hemorrhoid?

A Grade IV hemorrhoid is an internal hemorrhoid that remains prolapsed and cannot be manually pushed back inside.

Q. Which hemorrhoid grade is the most severe?

Grade IV represents the most advanced category in the standard four-grade internal hemorrhoid classification because the prolapsed tissue cannot be manually reduced. However, grade describes prolapse and should not be treated as a universal measure of pain or overall medical severity.

Q. What is the difference between Grade II and Grade III hemorrhoids?

The key difference is reduction. Grade II hemorrhoids come out during bowel movements but return inside on their own. Grade III hemorrhoids come out and require manual pushing to return inside.

Q. What is the difference between Grade III and Grade IV hemorrhoids?

Grade III hemorrhoids can be manually pushed back inside. Grade IV hemorrhoids remain prolapsed and cannot be manually reduced.

Q. Can Grade I hemorrhoids bleed?

Yes. Rectal bleeding can occur with internal hemorrhoids, including hemorrhoids that do not prolapse. Bright-red bleeding is a common symptom of internal hemorrhoids.

Q. Can Grade II hemorrhoids be treated without surgery?

Yes. Conservative treatment is commonly considered first, and selected Grade II hemorrhoids that remain symptomatic may be treated with office-based procedures such as rubber band ligation.

Q. Can Grade III hemorrhoids be treated without surgery?

Some Grade III hemorrhoids can be treated with office-based procedures. ASCRS notes that selected Grade III hemorrhoids that remain symptomatic despite conservative treatment may be effectively treated with office-based procedures.

Q. Do Grade IV hemorrhoids always require surgery?

Not every patient can be given the same treatment recommendation based only on grade. However, advanced Grade IV disease often requires specialist evaluation, and surgical treatment may be appropriate, particularly when symptomatic combined internal and external hemorrhoids are present.

Q. Can hemorrhoids change from one grade to another?

Hemorrhoid prolapse can change over time, but hemorrhoids do not necessarily progress through all four grades in a predictable sequence. The grade describes the prolapse behavior observed during clinical assessment.

Q. Are hemorrhoid grades the same as hemorrhoid stages?

The terms may be used informally in similar ways, but Grade I–IV is the standard classification commonly used for internal hemorrhoids based on prolapse.

Q. Are Grade IV hemorrhoids painful?

They can cause discomfort, irritation, swelling, or pain, but pain is not what defines Grade IV. The defining feature is persistent prolapse that cannot be manually reduced.

Q. Can external hemorrhoids be Grade I, II, III or IV?

The standard Grade I–IV classification is primarily used for internal hemorrhoids. External hemorrhoids are not generally classified using this same four-grade system.

Q. Can a lump outside the anus be a Grade IV hemorrhoid?

It could be an advanced prolapsed internal hemorrhoid, but a lump or tissue outside the anus can have other causes. Rectal prolapse, for example, can also cause tissue to protrude through the anus. A professional examination may be needed to determine the cause.

Q. How are hemorrhoid grades diagnosed?

A healthcare professional may review your symptoms and medical history, examine the anal area, perform a digital rectal examination, and use anoscopy or another examination method when appropriate.

Q. Does hemorrhoid grade determine treatment?

Grade is an important consideration, but treatment also depends on symptoms, the presence of internal and external disease, previous treatments, overall health, and other clinical findings.

Q. When should I see a doctor about hemorrhoids?

You should seek medical evaluation for rectal bleeding, persistent symptoms, severe pain, recurrent prolapse, or tissue that remains outside the anus. Persistent bleeding should not automatically be assumed to be caused by hemorrhoids because other conditions can produce similar symptoms.

Final Takeaway

The hemorrhoid grading system helps describe how far internal hemorrhoids prolapse and whether they return inside the anus.

The four grades can be remembered simply:

Grade I: Internal hemorrhoid with no prolapse.

Grade II: Prolapses during bowel movements but returns on its own.

Grade III: Prolapses and requires manual reduction.

Grade IV: Remains prolapsed and cannot be manually reduced.

The grade can help healthcare professionals select an appropriate treatment strategy, but it does not tell the entire story. Symptoms, anatomy, bowel habits, previous treatments, and whether internal and external hemorrhoids are both present also matter.

Many symptomatic Grade I and Grade II hemorrhoids can initially be managed with dietary and behavioral changes, while selected Grade II and Grade III hemorrhoids may be candidates for office-based treatments such as rubber band ligation. More advanced disease may require surgical evaluation.

Most importantly, do not assume that rectal bleeding or tissue protruding from the anus is automatically a hemorrhoid. Other anorectal and gastrointestinal conditions can produce similar symptoms.

If you have persistent bleeding, significant pain, recurrent prolapse, or tissue that cannot be pushed back inside, professional evaluation can help determine the actual cause and the most appropriate treatment.