Hemorrhoid Grades 1 to 4: Staging and Treatment Explained
Hemorrhoid Grades (Stages 1 to 4)
Grading is the single most useful piece of information for planning hemorrhoid treatment. It applies to internal hemorrhoids and describes one thing: how far the tissue prolapses, that is, slides down through the anal opening. The higher the grade, the more the balance shifts from simple measures toward a procedure.
Hemorrhoid grading describes how far internal hemorrhoid tissue prolapses. Grade 1 stays inside; Grade 4 remains outside and cannot be reduced.
Grade is about prolapse, not bleeding severity. Treatment choice depends on grade, symptoms, examination findings and patient-specific factors.
How the grading system works
The system runs from Grade 1 to Grade 4 and is based purely on prolapse, not on how much they bleed or hurt. It applies to internal hemorrhoids; external hemorrhoids are described differently because they sit outside the anal canal.
| Grade | What happens | Usual direction of treatment |
|---|---|---|
| Grade 1 | Bulge into the canal, may bleed, no prolapse outside | Conservative care |
| Grade 2 | Prolapse on straining, reduce on their own afterwards | Conservative care or office procedure |
| Grade 3 | Prolapse that must be pushed back by hand | Laser or procedural treatment |
| Grade 4 | Prolapse that stays out and cannot be reduced | Surgical or combined approach |
Grade 1
The hemorrhoid bulges into the canal but does not come outside. The most common sign is painless bleeding. At this stage the conservative measures of fibre, fluids and avoiding strain usually do the job.
Grade 2
Now the tissue slides out a little during a bowel movement but returns on its own. Symptoms are more noticeable but the disease is still very treatable without surgery.
Grade 3
The prolapse no longer reduces by itself and has to be pushed back manually. This is the stage where a procedure such as laser treatment often becomes the most sensible choice.
Grade 4
The tissue remains prolapsed and cannot be returned. Treatment is individualised and may involve a surgical or combined approach, which is discussed on the hemorrhoid surgery page.
Knowing your grade is the start; choosing the right option is covered on the hemorrhoid treatment page, and the whole condition is summarised in the complete hemorrhoid guide.
Frequently Asked Questions
Can a low-grade hemorrhoid become a higher grade?
Yes. Continued straining and constipation can let a Grade 1 or 2 hemorrhoid progress over time, which is why correcting habits early matters.
Which grade needs surgery?
Grade 4, and some recurrent Grade 3 cases, are most likely to need a surgical or combined approach. Lower grades are usually managed without surgery.
Does a higher grade mean more bleeding?
Not necessarily. Grading measures prolapse, not bleeding; a Grade 1 hemorrhoid can bleed noticeably while a Grade 4 may bleed little.
Same-day treatment in Istanbul
Laser and laser-assisted hemorrhoid procedures with no hospital stay and a return to daily life the same day.
This article was written and medically reviewed by Dr. Yasir Gozu for accuracy and adherence to current clinical practice.
- Reviewed by
- Dr. Yasir Gozu
- Specialty
- Proctology
- Institution
- Avrupa Cerrahi, Levent, Istanbul
- Experience
- 20+ years
- Last reviewed
- 1 June 2026
- Next review
- December 2026
References
- Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024;67(5):614-623. doi:10.1097/DCR.0000000000003276 (via PubMed)
- Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021;116(10):1987-2008. doi:10.14309/ajg.0000000000001507 (via PubMed)
- Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician. 2018;97(3):172-179. PMID:29431977 (via PubMed)
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Hemorrhoids. U.S. National Institutes of Health. niddk.nih.gov
This content is for informational purposes only and does not constitute medical advice or a medication recommendation. It does not name specific drugs or dosages; the appropriate medication and dose are determined by your doctor. Always consult a qualified physician for diagnosis and treatment of your individual condition.
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