Medically reviewed by
USA Clinics Medical Review Team
Reviewed August 2026
Internal hemorrhoids are classified into four grades based on how much the tissue prolapses, or slides out, of the anal canal. Grade 1 stays inside; Grade 4 stays permanently outside. Knowing your grade helps a hemorrhoid specialist determine whether lifestyle adjustments may help manage symptoms or whether a minimally invasive procedure like hemorrhoid artery embolization (HAE) may be appropriate for your situation.
We will cover how the grading system works, what each stage feels like, and what questions to ask if you are not sure what grade you may have.
What Is the Hemorrhoid Grading System?
The hemorrhoid grading system, sometimes called the Goligher classification, was developed to give physicians and patients a shared language for describing internal hemorrhoid severity.[1] It applies only to internal hemorrhoids, which form inside the anal canal above the dentate line. External hemorrhoids, which develop under the skin around the anus, are not classified using this system.
Grades are assigned based on one primary factor: whether the hemorrhoidal tissue prolapses (extends outside the anal opening), and if so, whether it returns on its own or requires manual help. The higher the grade, the further the tissue has descended and the less able it is to return on its own.
This distinction matters because it directly influences what kind of evaluation and care may be appropriate.
Internal vs. External: Why the Distinction Matters for Hemorrhoid Grading
Because the grading system applies only to internal hemorrhoids, it is worth clarifying the difference. Internal hemorrhoids develop in the upper anal canal, in tissue that has fewer pain-sensing nerve endings, which is why they often cause painless bleeding before they cause discomfort. External hemorrhoids develop in the lower canal and surrounding skin, where nerve density is higher, making them more immediately painful.
A prolapsed hemorrhoid – one that has extended outside the opening – can be mistaken for an external hemorrhoid. Understanding which type you have affects what kind of care is appropriate, which is why a specialist evaluation matters rather than self-diagnosis.
Grade 1 Internal Hemorrhoids
A Grade 1 hemorrhoid has enlarged inside the anal canal but does not extend outside the anus.[1] It may dip below the dentate line, but it does not prolapse through the anal opening.
At this stage, most people notice bleeding, particularly bright red blood on toilet paper or in the bowl after a bowel movement. Itching around the anus is also common. Pain is usually minimal or absent, since the tissue sits above the area with the most pain-sensing nerves.
Because Grade 1 hemorrhoids are not yet prolapsing, they are often the most responsive to conservative measures: increasing dietary fiber, staying well hydrated, and avoiding prolonged straining on the toilet. In some cases, internal hemorrhoids can go away on their own, particularly when symptoms are mild and contributing factors are addressed. Persistent internal hemorrhoid symptoms at this stage warrant evaluation to confirm the diagnosis and assess whether additional options may help.
Grade 2 Internal Hemorrhoids
A Grade 2 hemorrhoid prolapses during bowel movements or straining, then returns to its position inside the anal canal on its own once the straining stops.[1] This self-reduction is the defining feature of Grade 2.
Symptoms are similar to Grade 1, including bleeding, itching, and occasional discomfort, with the addition of a sensation of tissue briefly protruding. This can feel like pressure or a temporary bulge that resolves after a bowel movement. Some people are not aware this is happening unless symptoms prompt a closer look.
Grade 2 hemorrhoids can still respond to lifestyle adjustments, but if symptoms recur frequently or persist, a specialist evaluation makes sense. A hemorrhoid specialist can assess the size and frequency of prolapse and discuss whether a minimally invasive option like HAE may be appropriate for your situation.
Grade 3 Internal Hemorrhoids
At Grade 3, hemorrhoidal tissue prolapses during bowel movements and does not return on its own. It requires manual reduction, meaning gently pushing the tissue back inside.[1] This is the defining difference between Grade 2 and Grade 3.
Symptoms at this stage tend to be more persistent. The tissue that protrudes can cause ongoing irritation, a sensation of fullness or incomplete emptying, mucus discharge, and recurring bleeding. Discomfort when sitting is more common at Grade 3 than at earlier hemorrhoid stages.
Evaluation by a hemorrhoid specialist is recommended at Grade 3. The need to manually reduce tissue indicates that the supporting structures have weakened enough that lifestyle changes alone are unlikely to resolve the underlying issue. HAE is one option evaluated at this stage; a specialist can determine candidacy based on anatomy, symptom severity, and medical history.
Grade 4 Internal Hemorrhoids
Grade 4 hemorrhoids remain prolapsed outside the anal opening and cannot be pushed back inside.[1] The tissue is permanently external and exposed, which can cause significant ongoing discomfort, continuous mucus discharge, hygiene difficulties, and recurring bleeding.
Grade 4 hemorrhoids require specialist evaluation. The extent of prolapse and the tissue involved means that a clinical assessment is needed to determine what options are appropriate for each individual situation. Delaying evaluation at Grade 4 is not recommended, since leaving hemorrhoids untreated can lead to worsening symptoms and additional complications over time.
How Is Hemorrhoid Grade Determined?
You cannot reliably determine your own hemorrhoid grade at home. A hemorrhoid specialist confirms the grade through a clinical examination, which typically involves visual inspection and anoscopy, a short, minimally invasive exam that allows direct visualization of the anal canal.[2]
The exam is generally brief and well-tolerated. Its purpose is not only to confirm the grade but also to rule out other conditions that can cause similar symptoms, including anal fissures and, in some cases, colorectal conditions that require a different kind of attention.
If you have been experiencing rectal bleeding, prolapse, or persistent anal discomfort, a specialist evaluation is the appropriate next step rather than waiting to see whether symptoms resolve. Earlier grades generally have more options available, and addressing symptoms before they progress can make management more straightforward.
Can USA Hemorrhoid Centers Help?
USA Hemorrhoid Centers evaluates and treats internal hemorrhoids using hemorrhoid artery embolization (HAE), a minimally invasive, image-guided procedure performed by experienced interventional radiologists. HAE works by reducing blood flow to the hemorrhoidal tissue, which can help shrink the hemorrhoids and relieve symptoms without incisions or general anesthesia.
HAE is typically performed as an outpatient procedure. Candidacy depends on the grade and type of hemorrhoids present, overall health, and other factors reviewed during a consultation. Not every patient is a candidate, which is why an evaluation comes first.
If you have been noticing blood after bowel movements, tissue that protrudes, or discomfort that affects your daily routine, a consultation with a hemorrhoid specialist can give you a clear picture of what is happening and what options may fit your situation. Learn more about internal hemorrhoid symptoms to help you understand what to bring to that conversation.
Treatment option: hemorrhoid treatment
Whether Hemorrhoid Grades Are Manageable Depends on Getting the Right Evaluation
The grading system exists to help connect your symptoms to the right level of care. A Grade 1 hemorrhoid and a Grade 4 hemorrhoid are meaningfully different experiences, and they may call for different approaches. Understanding your grade is the first step toward knowing what options are available to you.
USA Hemorrhoid Centers offers minimally invasive, outpatient evaluation and treatment performed by experienced interventional radiologists. Procedures are completed in the office, typically in under an hour, with no general anesthesia required and a rapid return to daily activities for most patients. The first step is a consultation to evaluate your symptoms and discuss the options that fit your situation.
FAQs About Hemorrhoid Grades and Stages
- Fontem RF, Eyvazzadeh D. Internal Hemorrhoid. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026. https://www.ncbi.nlm.nih.gov/books/NBK537182/
- 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.
- Kim SY, et al. Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults. Scientific Reports. January 7, 2022. https://www.nature.com/articles/s41598-021-03838-z
Medical disclaimer: This content is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare provider with any questions you may have regarding a medical condition.
Frequently Asked Questions
A prolapsed internal hemorrhoid is tissue that has extended outside the anal opening from inside the canal. An external hemorrhoid forms under the skin around the outside of the anus from the start. The two can look similar, which is why a specialist examination matters. An external hemorrhoid tends to cause more immediate pain because it develops in tissue with more pain-sensing nerves. A prolapsed internal hemorrhoid may cause less acute pain but more bleeding and mucus.
Not always, but progression is possible, particularly when contributing factors like chronic straining, low-fiber diet, or prolonged sitting on the toilet are not addressed. A Grade 1 hemorrhoid that is not managed may gradually progress to Grade 2 or Grade 3 over time.[3] Whether or not progression occurs varies by individual. This is one reason early evaluation and appropriate lifestyle adjustment can be useful: addressing contributing factors early may help reduce the likelihood of symptoms worsening.
Any grade of internal hemorrhoid that causes persistent symptoms, including recurrent bleeding, prolapse, or discomfort that interferes with daily activity, warrants evaluation rather than continued waiting. Grade 1 and Grade 2 hemorrhoids often respond to conservative measures, but if symptoms recur or are not improving, a specialist can assess whether a minimally invasive option may be appropriate. Grade 3 hemorrhoids that require manual reduction are generally a signal that specialist evaluation is the right next step. Grade 4 hemorrhoids require evaluation without delay.
Hemorrhoid grade is confirmed through a clinical examination. A specialist typically performs a visual inspection of the perianal area, a digital rectal examination, and anoscopy, a brief procedure that uses a small, lighted scope to directly visualize the anal canal. The exam is short and well-tolerated in most cases. Self-assessment alone is not reliable for confirming grade because the key distinctions, whether tissue prolapses and whether it reduces spontaneously, require clinical observation.
Grade 4 hemorrhoids are permanently prolapsed and do not reduce on their own or with manual assistance. At this stage, lifestyle measures alone are not sufficient to address the prolapse. A specialist evaluation is needed to determine what approach is appropriate based on the individual’s anatomy and overall health. Options discussed during a consultation depend on each patient’s specific clinical picture.
HAE candidacy depends on several factors evaluated during a consultation, including hemorrhoid grade, anatomy, symptom severity, and medical history. Not every patient is a candidate. HAE is one option that experienced interventional radiologists at USA Hemorrhoid Centers may discuss for appropriate internal hemorrhoid cases. A thorough evaluation comes first in all cases.
Sources
- Fontem RF, Eyvazzadeh D. Internal Hemorrhoid. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026. https://www.ncbi.nlm.nih.gov/books/NBK537182/
- 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.
- Kim SY, et al. Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults. Scientific Reports. January 7, 2022. https://www.nature.com/articles/s41598-021-03838-z