Most adults aren’t strangers to hemorrhoids, which are ‘piles’ of veins and connective tissue around the anus that have become swollen and inflamed. Roughly 20% of the US population has been diagnosed with them.1 Depending on the hemorrhoids’ stage, some people may experience no symptoms while others may suffer from chronic pain and discomfort.
Knowing which stage of hemorrhoids you have can help determine when and how they should be treated.
Doctors use a grading system to categorize hemorrhoids by their severity. These hemorrhoid stages, also known as hemorrhoid grades, are used to determine whether medical treatment is necessary and what type of procedure to use to treat them.
You can’t necessarily confirm the hemorrhoid grading you have at home. A hemorrhoid doctor will need to give you a diagnosis after an exam.
However, you can get a good idea of how serious your hemorrhoids are by understanding the stages of hemorrhoids and what symptoms to expect with each one.
What Is the Hemorrhoid Grading System?
The hemorrhoid grading system assigns a grade to internal hemorrhoids based on their severity. This system does not categorize external hemorrhoids.
It’s important to first learn about the dentate line to better understand hemorrhoid grading and the difference between internal and external hemorrhoids.
The dentate line is where the rectum becomes the anal canal.2 It’s a zig-zagging line that separates the two regions. The upper section — the rectum — is supplied by different nerve cells and has a different type of tissue lining than the lower section — the anal canal.
- Internal hemorrhoids develop in the rectum or above the dentate line.
- External hemorrhoids form under the skin along the anal canal or below the dentate line.
The different grades of hemorrhoids relate to whether an internal hemorrhoid slips below the dentate line and protrudes outside of the anus and how difficult it is to move it inside again. This level of prolapse or slippage dictates what type of hemorrhoid treatment will be effective for alleviating symptoms and treating the hemorrhoid.
Understanding the 4 Grades of Hemorrhoids
Internal hemorrhoids are classified into four grades, also referred to as stages.
Here’s an overview of the symptoms of each stage and possible treatment options based on the grading.
Grade 1 Hemorrhoid
A grade 1 hemorrhoid is an enlarged hemorrhoid that isn’t visible outside of the anus. They can fall below the dentate line into the anal canal, but they don’t protrude outside of the anus. These hemorrhoids aren’t usually painful but can cause uncomfortable symptoms, such as bleeding and anal itching.
Treatment for grade 1 hemorrhoids can include adding fiber to the diet and over-the-counter hemorrhoid creams to relieve the swelling, itching, and irritation.
If a grade 1 hemorrhoid causes persistent symptoms after making lifestyle changes, your doctor might recommend a minimally invasive procedure to treat the hemorrhoids, such as hemorrhoid artery embolization (HAE). This treatment is a painless procedure that is effective for grades 1 through 3.
Grade 2 Hemorrhoid
A grade 2 hemorrhoid will prolapse or come out of the anus during straining from passing a stool or exercise. It then retracts to its original position on its own.
This type of hemorrhoid can cause the same symptoms as a stage 1 hemorrhoid, including blood in the stool and itching or burning. It can also cause pain and discomfort when bulging outside of the anus, although this discomfort is temporary.
Treatment options for stage 2 hemorrhoids include non-surgical procedures, such as HAE, infrared coagulation, rubber band ligation, and sclerotherapy.
Your doctor might also recommend conservative treatment to start, such as using stool softeners, eating more fiber, or taking over-the-counter or prescription-strength hemorrhoid creams. The recommended treatment depends on the size of the hemorrhoid and the severity of symptoms, which is why it is suggested to consult a specialist.
Grade 3 Hemorrhoid
A grade 3 hemorrhoid slips out of the anus due to straining, but it has to be manually returned to its position. It won’t go back inside the anal canal unless it’s pushed back inside.
A stage 3 hemorrhoid can cause similar symptoms as stage 1 and 2 hemorrhoids, but it’s also more likely to be painful, especially when sitting down.
Hemorrhoid treatment options include the same non-surgical procedures that are effective for grade 2 hemorrhoids. A doctor will assess your size to recommend the best treatment for you and see if you are a candidate for HAE.
Grade 4 Hemorrhoid
This type of hemorrhoid is permanently prolapsed. It’s always outside of the anus, which can cause severe pain, discomfort, and stress. A large grade 4 hemorrhoid can make even something as simple as sitting down difficult.
A grade 4 hemorrhoid is more challenging to treat and typically requires a hemorrhoidectomy. This surgical option can be the most effective in serious cases — the recurrence rate after a hemorrhoidectomy is between 5 and 10%.3 However, it can cause complications, such as severe pain and loss of continence. Consulting a medical doctor is the best way to receive an accurate diagnosis for your hemorrhoid grade and to determine the best course of action for treating Stage 4 hemorrhoids.
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How to Determine Your Hemorrhoid Stage
Recognizing the typical symptoms of each stage can help you determine the grade of your hemorrhoids, while a doctor will be able to confirm and provide a treatment plan.
- Grade 1 hemorrhoids often cause bleeding, and they can cause anal itching.
- Grade 2 hemorrhoids will slip out of the anal canal, usually during a bowel movement. At that point, they might cause pain in addition to other internal hemorrhoid symptoms.
- Grade 3 hemorrhoids require manual replacement. If an internal hemorrhoid has fallen out of the anal canal and you can push it back in, it’s likely a grade 3.
- Grade 4 hemorrhoids are always outside of the anus and can be very painful.
When to Seek Treatment for Hemorrhoids
If you have symptoms of internal hemorrhoids, including blood in the stool, itching, and pressure when passing a stool, schedule a consultation with a hemorrhoid doctor near you. For symptoms that don’t go away after a few days of lifestyle changes to relieve hemorrhoids, consulting a doctor is recommended.
At USA Hemorrhoid Centers, our doctors will evaluate your symptoms and develop a personalized treatment plan to help relieve hemorrhoid symptoms. We offer hemorrhoid artery embolization (HAE), which is a safe and effective treatment for grade 1, 2, and 3 hemorrhoids. Leaving hemorrhoids untreated can increase the risk of further progression and more intensive treatment, so it’s important to address hemorrhoids in the early stages.
Frequently Asked Questions
How can you tell the difference between a prolapsed internal hemorrhoid and an external hemorrhoid?
A prolapsed internal hemorrhoid will feel like a soft lump that’s visibly hanging outside of the anus. An external hemorrhoid develops under the skin in the anal canal and feels like a hard lump.
Do hemorrhoids get progressively worse?
Hemorrhoids that are left untreated can get progressively worse, causing more severe symptoms. They’re also less likely to respond to conservative treatments, such as changing your diet to include more fiber and stool softeners.
At what stage should hemorrhoids be treated?
It’s best to treat hemorrhoids early on because they’re more responsive to treatment when they are at one of the earlier hemorrhoid stages. Schedule a consultation with a hemorrhoid doctor if you have symptoms of stage 1 or 2 hemorrhoids for more than a few days to prevent more severe symptoms from developing.
Sources
- Sandler, R. S., & Peery, A. F. (2019). Rethinking What We Know About Hemorrhoids. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 17(1), 8–15.
- Lawrence A, McLaren ER. External Hemorrhoid. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
- Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Overview: Enlarged hemorrhoids. [Updated 2021 Dec 9].
