What internal hemorrhoid grades mean

A grade is a way these two pages sort an internal hemorrhoid. It is not a label a person can assign from symptoms at home. ahem does not examine people. The pages were opened October 27, 2026.

The American Society of Colon and Rectal Surgeons prints the scale on its expanded patient page. That page does not show a review date. Grade one is no prolapse. Grade two is prolapse that goes back in on its own. Grade three is prolapse that must be pushed back in by the patient. Grade four is prolapse that cannot be pushed back in by the patient, and the page adds that this is often very painful. Prolapse, in its words, is hemorrhoidal tissue from the inside that can be felt on the outside when wiping or having a bowel movement.

The Merck Manual Professional Version lists a full review and a last update of January 2025. Its table, adapted from the society's 2024 guideline, uses the same four steps with a few extra words. Grade I is prominent hemorrhoids with no prolapse. Grade II prolapses after a Valsalva maneuver and reduces spontaneously. Grade III prolapses after a Valsalva maneuver and needs manual reduction. Grade IV is chronic prolapse, and manual reduction is ineffective. The society page does not use the term Valsalva maneuver.

The scale is for internal hemorrhoids. The society page separates external hemorrhoids, which can be a bluish painful lump just outside the anus, often after straining. Merck says external hemorrhoids are below the dentate line and may thrombose into a painful purplish swelling. Neither page turns that external clot into a grade on this scale.

Rectal prolapse, the rectum itself coming out, is a different finding. How those pages separate it from a prolapsed hemorrhoid is on a prolapsed hemorrhoid and rectal prolapse. How long a clot is timed on the hemorrhoid treatment pages is on how long hemorrhoid symptoms usually last.

• Grade 1: no prolapse, on both pages. Merck adds that the hemorrhoids are prominent.
• Grade 2: prolapse that returns on its own. Merck places that prolapse after bearing down.
• Grade 3: someone has to push it back. Merck again places the prolapse after bearing down.
• Grade 4: it cannot be kept inside. The society adds that this is often very painful. Merck calls the prolapse chronic.

The society says rubber band ligation can be used for grades 1, 2, and some grade 3 internal hemorrhoids. Infrared coagulation is for grades 1 and 2 and occasional grade 3. Sclerotherapy is for grades 1 and 2. These office procedures, it says, are for internal hemorrhoids and do not apply to external hemorrhoids. On the page opened October 27, 2026, banding places one to three bands at a visit, the tissue falls off with the band at roughly 5 to 7 days, and there may be a small amount of bleeding then. A dull ache or pressure can last 1 to 3 days. Someone taking Coumadin, heparin, or Plavix may not be a candidate for banding.

Merck says patients with grades I and II, and some with grade III who do not respond to symptomatic treatment, can often be treated with injection sclerotherapy, rubber band ligation, or infrared photocoagulation. Rubber band ligation, on that page, is for larger prolapsing internal hemorrhoids, bleeding internal hemorrhoids, or hemorrhoids that do not respond to conservative care. Only the internal part of a mixed hemorrhoid should be banded. External hemorrhoids should not be banded. Infrared coagulation is for nonprolapsing, bleeding internal hemorrhoids, or hemorrhoids not cured with banding. Merck's visit line is different from the society's. It says one hemorrhoid is typically ligated every 2 weeks, and that 3 to 6 treatments may be required. Several hemorrhoids at one visit may cause more pain. The 5-to-7-day fall-off and the 1-to-3-day ache are the society's figures. The every-2-weeks schedule is Merck's. This page does not merge them into one calendar.

NIDDK and Mayo Clinic describe the same office procedures without this grade table. That account is on office treatments for hemorrhoids.

The society says hemorrhoidectomy may be considered for symptomatic large external hemorrhoids, combined internal and external hemorrhoids, and grade 3 or grade 4 prolapse. It is done in an operating room. A stapled or suture hemorrhoidopexy, which pulls the tissue upward, is another operation it names.

Merck says surgical hemorrhoidectomy is for people who do not respond to other therapy and for grade IV internal hemorrhoids. Significant pain afterward is common, as are urinary retention and constipation. Stapled hemorrhoidopexy, on that page, is an alternative for circumferential hemorrhoids, with less postoperative pain and higher recurrence and complication rates than conventional hemorrhoidectomy. The overlap is grade 4 and hemorrhoids that have not responded to simpler care. The society also puts some grade 3 prolapse on the surgery list. Merck keeps some grade III on the office-procedure list. The choice stays with the clinician who has done the exam.

How NIDDK and Mayo Clinic compare removal and stapling is on hemorrhoidectomy and hemorrhoid stapling.