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Hemorrhoid grades describe how far internal hemorrhoids protrude and whether the tissue returns inside the anus. A higher grade indicates more prolapse, but it does not automatically mean surgery. Depending on the symptoms and examination findings, treatment ranges from changes in bowel habits to office-based procedures or an operation.
Hemorrhoids develop when repeated pressure weakens the tissues that support the blood vessels inside the anus and lower rectum. Several factors contribute to this pressure:
As this support weakens, internal hemorrhoids begin to protrude during bowel movements. The extent of the prolapse determines the grade.
Doctors classify internal hemorrhoids by what happens when the tissue prolapses. It either stays inside, protrudes and returns on its own, requires manual repositioning, or remains outside the anus. Pain and bleeding do not determine the grade.
The four grades differ mainly in the extent of prolapse and whether the tissue returns inside the anus.
| Hemorrhoid grade | Degree of prolapse | Common symptoms |
| Grade 1 | Remains inside the anal canal with no visible prolapse | Painless, bright-red bleeding during or after a bowel movement |
| Grade 2 | Protrudes during a bowel movement but returns inside on its own | Bleeding, itching, irritation, or a lump that disappears afterward |
| Grade 3 | Protrudes during a bowel movement or physical strain and requires manual repositioning | Discomfort, mucus discharge, irritation, and difficulty keeping the area clean |
| Grade 4 | Remains outside the anus and cannot be pushed back in | Persistent swelling, irritation, discomfort, bleeding, or hygiene problems |
The grade reflects the extent of prolapse rather than the severity of pain or bleeding. One person with Grade 1 hemorrhoids might experience frequent bleeding, while another with Grade 3 reports only mild discomfort. Doctors therefore assess the symptoms and examination findings alongside the grade before discussing treatment.
A higher grade indicates a greater degree of prolapse, but it does not automatically lead to surgery. Doctors also consider the frequency of bleeding and prolapse, the level of discomfort, the impact on daily life, and the response to previous treatment.
The grade helps narrow the options, but the full clinical assessment determines the most suitable treatment.
Bright-red blood on toilet paper, stool, or in the toilet bowl commonly occurs with internal hemorrhoids. The appearance of the blood alone does not confirm its source. Anal fissures, bowel inflammation, polyps, and colorectal cancer also cause rectal bleeding.
A medical evaluation becomes particularly important when bleeding:
Heavy bleeding, dizziness, or fainting requires urgent medical attention. An examination helps identify the source rather than assuming that hemorrhoids caused the bleeding.
Read more about the differences in Rectal Bleeding: Hemorrhoids or Colon Cancer.
Hemorrhoid grade is one of several factors doctors consider when choosing the most appropriate treatment. At the Surgery Center, Vejthani International Hospital, specialists evaluate the hemorrhoid grade, degree of prolapse, symptoms, and possible causes of rectal bleeding before recommending treatment. Whenever possible, the least invasive option suitable for the patient is considered, while surgery may be recommended for significant prolapse or persistent symptoms.
The grade depends on the degree of prolapse, not the severity of pain or bleeding. A doctor confirms it by examining whether the tissue stays inside, returns on its own, requires manual repositioning, or remains outside the anus.
Yes. Office-based procedures such as rubber band ligation remain suitable for selected Grade 3 hemorrhoids. Frequent prolapse, recurring symptoms, or unsuccessful previous treatment often make surgery a more appropriate choice
Hemorrhoids do not always progress, but repeated straining and ongoing constipation can weaken the supporting tissue and worsen the prolapse over time. Improving bowel habits helps reduce pressure, although existing Grade 3 or Grade 4 prolapse rarely returns to an earlier grade without treatment.
No. The grade reflects the degree of prolapse rather than the amount of bleeding. Grade 1 hemorrhoids sometimes cause frequent bleeding, while higher-grade hemorrhoids do not always bleed heavily. Persistent or heavy rectal bleeding still requires medical evaluation.
For more information, please contact
Surgery Center, Vejthani International Hospital
Call: (+66)2-734-0000 Ext. 4500, 4501
English Hotline: (+66)85-223-8888
