Hemorrhoid Grades I–IV Explained
Internal hemorrhoids are classified into four grades based on the degree of prolapse — how much the tissue descends and protrudes from the anus. This grading system is one of the main things a doctor’s exam actually determines, and it meaningfully guides which treatment options are appropriate.
- Grading is based specifically on the degree of prolapse, not on pain level, bleeding amount, or size alone.
- Higher grades generally correspond to more treatment options being needed beyond self-care, though grade alone doesn’t determine every treatment decision.
- Grade IV — permanently prolapsed, not reducible — generally requires surgery rather than office-based procedures.
Grade I
No prolapse. Internal hemorrhoids may bleed but don’t protrude from the anus at all, even with straining. Often managed with self-care alone (see Home care for hemorrhoids), sometimes with an office procedure if bleeding is persistent.
Grade II
Prolapses with straining or a bowel movement, but reduces (goes back in) on its own without needing to be pushed. Often still manageable with self-care, though office procedures (rubber band ligation, sclerotherapy, and similar) are commonly used if symptoms are persistent or bothersome.
Grade III
Prolapses with straining or a bowel movement and needs to be manually pushed back in — it doesn’t reduce on its own. Office procedures remain an option at this stage for many patients, though surgery becomes more likely to be discussed, particularly for larger or more symptomatic grade III disease.
Grade IV
Permanently prolapsed — outside the anus at all times, and can’t be pushed back in even manually. Office-based procedures generally aren’t sufficient at this stage; surgery is the standard recommendation (see Surgery for grade IV / strangulated hemorrhoids).
How grade relates to treatment, generally
| Grade | Typical first approach |
|---|---|
| I | Self-care; office procedure if persistent |
| II | Self-care; office procedure commonly used |
| III | Office procedure or surgery, depending on specifics |
| IV | Surgery |
This is a general pattern, not a rigid rule — your doctor’s recommendation also depends on your specific symptoms, whether external disease is also present, and your own preferences once options are explained (see Comparing office procedures and Comparing surgical options).
How grade is actually determined
Grading is done through a doctor’s exam — visual inspection, sometimes asking you to strain to see if and how tissue prolapses, and a digital rectal exam or anoscopy for a closer look. It’s not something you can reliably self-assess, since the specific behavior (does it reduce on its own, does it need to be pushed, is it permanently out) requires direct observation.
A note on illustrations
A visual comparison of the four grades side by side is one of the most requested and most useful additions to content like this — see the site’s broader illustration library plan for a diagram specifically comparing all four grades, since text descriptions alone are a less effective way to convey what “prolapse” actually looks like at each stage.
This page is for general education. Grading is determined by a doctor’s exam, not self-assessment.