Hemorrhoids are a common medical condition that affect millions of people worldwide. While often a source of discomfort and embarrassment, hemorrhoids are actually a normal part of our anatomy that only become problematic when inflamed or enlarged. In order to determine the most effective treatment options, healthcare providers classify hemorrhoids into different grades based on their severity and characteristics. This grading system plays a crucial role in tailoring treatment approaches to individual cases, ensuring that patients receive the most appropriate care for their specific condition.

What Are Hemorrhoids?

Hemorrhoids, also known as piles, are swollen and inflamed veins in the lower rectum and anus. These vascular structures, composed of hemorrhoidal tissue, are a normal part of the human anatomy and play a role in continence by helping to control bowel movements. However, when these veins become enlarged or inflamed, they can cause a range of uncomfortable symptoms and complications.

There are two main types of hemorrhoids: internal and external. Internal hemorrhoids develop inside the rectum and are typically painless, though they may cause bleeding during bowel movements. External hemorrhoids form under the skin around the anus and can be more painful, especially if they become thrombosed (develop blood clots). Both types can lead to discomfort, itching, and in some cases, prolapse, where the hemorrhoid protrudes from the anus.

Common hemorrhoid symptoms include rectal bleeding (bright red blood on toilet paper or in the toilet bowl), itching or irritation in the anal area, pain or discomfort, swelling around the anus, and a lump near the anus that may be sensitive or painful. In cases of prolapsed hemorrhoids, you may feel a soft, tender mass protruding from the anus. It’s important to note that while these symptoms are often indicative of hemorrhoids, they can also be signs of other, more serious conditions, making proper diagnosis essential. Pregnancy and obesity can also increase the risk of developing symptomatic hemorrhoids.1

The Four Grades of Hemorrhoids

The grading system for hemorrhoids is a valuable tool that healthcare providers can use to assess the severity of internal hemorrhoids and determine the most appropriate treatment approach. This system categorizes internal hemorrhoids into four grades, each representing a different level of severity and requiring potentially different management strategies. It’s important to note that this grading system applies specifically to internal hemorrhoids. External hemorrhoids, while not included in this grading system, can still cause significant discomfort and may require specific treatments, especially if they become thrombosed.

Grade I: This is the mildest form of internal hemorrhoids. These hemorrhoids may bleed but do not prolapse or protrude from the anal canal. They are typically not visible during an external examination and may only be detected through an internal examination or anoscopy. Despite their mild nature, Grade I hemorrhoids can still cause discomfort and may require treatment to alleviate symptoms.

Grade II: These hemorrhoids may prolapse during bowel movements or when straining, but they spontaneously retract back into the rectum. Like Grade I hemorrhoids, they may also bleed. Grade II hemorrhoids are more noticeable than Grade I but may still not be visible externally without straining. They often respond well to non-surgical treatments such as rubber band ligation or sclerotherapy.

Grade III: Hemorrhoids in this category prolapse during bowel movements or when straining and require manual pushing back into the rectum. They may bleed and can cause more significant discomfort than lower grades. Grade III hemorrhoids are more visible and can have a substantial impact on quality of life. They often require more aggressive treatment approaches, such as hemorrhoidectomy or stapled hemorrhoidopexy.

Grade IV: These are the most severe form of internal hemorrhoids. They are permanently prolapsed and cannot be pushed back into the rectum. Grade IV hemorrhoids can be quite painful and may become thrombosed, developing blood clots. They often require surgical intervention for effective treatment. These hemorrhoids can cause significant discomfort and may lead to complications if left untreated.2

Diagnosis and Treatment

Diagnosing hemorrhoids typically involves a thorough physical examination, including a digital rectal exam. During this exam, a healthcare provider will assess the size, location, and grade of any internal hemorrhoids. They may also use an anoscope, a small tube with a light, to get a better view of the anal canal and lower rectum. In some cases, particularly when there’s rectal bleeding or other concerning symptoms, a colonoscopy may be recommended to rule out other conditions such as colorectal cancer or inflammatory bowel disease.

Once a diagnosis is made and the grade of hemorrhoids is determined, a treatment plan can be developed. The approach to treatment varies depending on the severity of the hemorrhoids and the symptoms they’re causing. Here’s an overview of treatment options based on hemorrhoid grades:

  • For Grade I and some Grade II hemorrhoids, conservative treatments are often effective. These may include dietary changes (such as increasing fiber intake), over-the-counter creams and ointments, sitz baths, and avoiding straining during bowel movements. These approaches aim to reduce symptoms and prevent the hemorrhoids from worsening.
  • For more severe Grade II and some Grade III hemorrhoids, office-based procedures are often recommended. These minimally invasive treatments can include rubber band ligation, where a small elastic band is placed around the base of the hemorrhoid to cut off its blood supply, causing it to shrink and fall off. Other options include sclerotherapy, which involves injecting a chemical solution into the hemorrhoid to shrink it, or infrared coagulation, which uses infrared light to coagulate the hemorrhoid tissue.
  • For severe Grade III and Grade IV hemorrhoids, more extensive surgical interventions may be necessary. These can include hemorrhoidectomy (surgical removal of hemorrhoids) or stapled hemorrhoidopexy (a procedure that secures prolapsing hemorrhoids back in place). These procedures are typically reserved for the most severe cases or when other treatments have been ineffective and are usually performed in a hospital setting.3

    Prevention and Long Term Management

    Preventing hemorrhoid flare-ups and managing the condition long-term involves a combination of lifestyle modifications and good hygiene practices. By incorporating these preventive measures into your daily routine, you can significantly reduce the risk of developing hemorrhoids or experiencing symptom flare-ups if you already have them. Here are some key strategies to help prevent hemorrhoids and manage them effectively:

    • High-fiber diet: Consuming foods rich in fiber, such as fruits, vegetables, whole grains, and legumes, can help soften stools and make them easier to pass, reducing strain during bowel movements.
    • Hydration: Staying well-hydrated helps keep stools soft and prevents constipation, which can exacerbate hemorrhoids.
    • Regular exercise: Physical activity promotes healthy bowel function and improves overall circulation, which may help prevent hemorrhoids.
    • Proper toilet habits: Avoid straining during bowel movements and limit time spent on the toilet. Using a footstool to elevate your feet while on the toilet can help align the rectum for easier passage of stool.
    • Good hygiene: Gently clean the anal area after bowel movements, using moist wipes or water instead of dry toilet paper. Avoid harsh soaps that can irritate the area.
    • Avoid prolonged sitting or standing: Take breaks to move around or change positions to alleviate pressure on the veins in the anal area.
    • Sitz baths: Soaking the anal area in warm water for 10-15 minutes a few times a day can help relieve symptoms and promote healing.
    • Fiber supplements: In some cases, healthcare providers may recommend fiber supplements or stool softeners to help manage constipation and reduce the risk of hemorrhoid flare-ups.

    Contact Cary Gastro for Hemorrhoid Relief

    Hemorrhoids can unfortunately be an unpleasant experience, but they are a relatively common condition that can be successfully managed with proper care and treatment. If you’re experiencing symptoms of hemorrhoids or have concerns about your digestive health in general, the experienced team at Cary Gastro is here to help. Our specialists can provide a thorough evaluation, accurate diagnosis, and personalized treatment plan tailored to your specific needs. Don’t let hemorrhoid discomfort impact your quality of life—reach out to Cary Gastro today to take the first step toward relief and improved digestive health.


    1https://www.ncbi.nlm.nih.gov/books/NBK500009/
    2https://www.ncbi.nlm.nih.gov/books/NBK279467/
    3https://www.aafp.org/pubs/afp/issues/2018/0201/p172.html