Medical Reviewer: HemorrhoidsGuide Clinical Team | Last Updated: February 27, 2026
Key Points to Remember
- Internal hemorrhoids are classified into four distinct grades (I-IV), with each grade requiring different treatment approaches
- While Grades I and II can often be managed at home, Grades III and IV typically require medical intervention
- Any severe rectal bleeding or intense pain requires immediate medical attention, regardless of hemorrhoid grade
Understanding Internal Hemorrhoid Classifications
As a gastroenterologist with over 15 years of experience treating hemorrhoidal disease, I’ve observed that understanding the grading system is crucial for proper treatment. Internal hemorrhoids are classified into four grades based on their severity and presentation.
The Clinical Importance of Grading
The grading system helps medical professionals determine the most appropriate treatment approach and allows for standardized communication among healthcare providers. This classification was developed by Goligher and has become the worldwide standard for hemorrhoid assessment.
| Grade | Characteristics | Common Treatments | Recovery Time |
|---|---|---|---|
| Grade I | Bulging without prolapse | Conservative management, dietary changes | 2-4 weeks |
| Grade II | Prolapse with spontaneous reduction | Rubber band ligation, sclerotherapy | 3-6 weeks |
| Grade III | Prolapse requiring manual reduction | Hemorrhoidectomy, THD | 4-8 weeks |
| Grade IV | Irreducible prolapse | Surgical hemorrhoidectomy | 6-12 weeks |
Detailed Analysis of Each Grade
Grade I Internal Hemorrhoids
Grade I hemorrhoids represent the mildest form of internal hemorrhoids. They project slightly into the anal canal but don’t prolapse. Key characteristics include:
– Occasional bleeding during bowel movements
– No external protrusion
– Minimal discomfort
– Usually discoverable only through anoscopy
Treatment Approaches for Grade I
– Dietary modifications (increased fiber)
– Proper hydration
– Over-the-counter medications
– Sitz baths
Grade II Internal Hemorrhoids
These hemorrhoids prolapse during defecation but spontaneously retract. Symptoms include:
– More frequent bleeding
– Mild discomfort
– Prolapse during straining
– Spontaneous return to normal position
Treatment Approaches for Grade II
– Conservative management as with Grade I
– Rubber band ligation
– Infrared coagulation
– Sclerotherapy when appropriate
Grade III Internal Hemorrhoids
This grade represents a significant advancement in severity, requiring manual reduction. Characteristics include:
– Regular prolapse
– Manual pushing back required
– Increased bleeding risk
– Moderate to severe discomfort
Treatment Approaches for Grade III
– Minimally invasive procedures
– Transanal hemorrhoidal dearterialization (THD)
– Surgical intervention may be necessary
– Regular follow-up care
Grade IV Internal Hemorrhoids
The most severe grade, these hemorrhoids remain permanently prolapsed. Features include:
– Constant external protrusion
– High risk of strangulation
– Significant pain and discomfort
– Increased infection risk
Treatment Approaches for Grade IV
– Surgical hemorrhoidectomy
– Extended recovery period
– Pain management protocols
– Regular post-operative care
When to Seek Emergency Care
IMMEDIATE MEDICAL ATTENTION is required if you experience:
– Severe rectal bleeding
– Intense pain
– Fever with anal pain
– Unable to urinate
– Severe dizziness
Frequently Asked Questions
Can internal hemorrhoids become external hemorrhoids?
How long does it take for internal hemorrhoids to heal?
Can Grade IV hemorrhoids heal without surgery?
Scientific References
1. National Institute of Diabetes and Digestive and Kidney Diseases. “Hemorrhoids.” NIDDK, 2016.
2. American Society of Colon and Rectal Surgeons. “Practice Parameters for the Management of Hemorrhoids.” Diseases of the Colon & Rectum, 2018.
3. Mayo Clinic. “Hemorrhoids: Diagnosis and Treatment.” Mayo Foundation for Medical Education and Research, 2021.
Written by: Dr. Alistair Vance, MD
Dr. Vance is a board-certified gastroenterologist specializing in colorectal health with over 15 years of clinical experience.
