Hemorrhoid grades: what grade 1, 2, 3 and 4 piles mean and how they are treated

If you have been told that you have grade 1, grade 2, grade 3 or grade 4 hemorrhoids, the number can sound more alarming than it actually is. The good news is that hemorrhoid grading is relatively straightforward.

The four grades mainly describe how far an internal hemorrhoid has prolapsed, or come down through the anal canal, and whether it returns inside on its own. Grade 1 hemorrhoids remain inside. Grade 2 come out during bowel movements but go back in by themselves. Grade 3 come out and need to be pushed back manually. Grade 4 remain outside and cannot be pushed back in.

Importantly, the grade does not tell you exactly how much pain or bleeding you will have. Someone with grade 2 hemorrhoids may have significant symptoms, while another person with grade 3 hemorrhoids may have relatively little discomfort.

Treatment also does not automatically mean surgery. Depending on the grade, symptoms and examination findings, treatment can range from dietary and bowel-habit changes to medicines, office procedures such as rubber band ligation, or surgery.

What are hemorrhoids?

Hemorrhoids, commonly called piles, are swollen or enlarged vascular structures in and around the anus and lower rectum. They are broadly classified as internal hemorrhoids and external hemorrhoids.

Internal hemorrhoids develop inside the anal canal and lower rectum. External hemorrhoids develop underneath the skin around the anus. The traditional grade 1 to grade 4 classification is primarily used for internal hemorrhoids.

Constipation, hard stools, repeated straining, prolonged sitting on the toilet, chronic diarrhea, pregnancy, ageing and other factors can contribute to hemorrhoidal symptoms. Keeping stools soft and avoiding straining are important parts of treatment and prevention.

What does hemorrhoid grading mean?

The easiest way to understand the grades is to ask one question:

What happens when the hemorrhoid comes out?

This is a classification of prolapse, not a cancer staging system. Grade 4 hemorrhoids are therefore not the same thing as “stage 4 cancer.”

What is a grade 1 hemorrhoid?

A grade 1 hemorrhoid remains inside the anal canal and does not prolapse through the anus during a bowel movement.

Some people have no symptoms at all. Others may notice bright-red bleeding, particularly after passing stool. Internal hemorrhoids can bleed without causing significant pain.

How are grade 1 hemorrhoids treated?

Treatment usually begins conservatively. This may include:

• Increasing dietary fibre
• Drinking adequate fluids
• Treating constipation
• Avoiding straining
• Spending less time sitting on the toilet
• Using medicines or topical treatments when recommended

Dietary and behavioural changes are considered first-line treatment for symptomatic hemorrhoids.

If bleeding or other symptoms continue despite these measures, a doctor may consider an office-based treatment.

What is a grade 2 hemorrhoid?

A grade 2 hemorrhoid comes out through the anal opening during a bowel movement or straining but returns inside on its own once the bowel movement is over.

You may notice a small lump or sensation of tissue coming out while passing stool. It may then disappear without you having to push it back.

Bleeding, itching, irritation and mucus discharge can also occur.

Can a grade 2 hemorrhoid go away without surgery?

Yes, symptoms from grade 2 hemorrhoids can improve without surgery, particularly when constipation, hard stools and straining are addressed.

The 2024 American Society of Colon and Rectal Surgeons (ASCRS) guidelines state that most patients with symptomatic grade I and grade II hemorrhoids can be effectively treated with office-based procedures when conservative treatment is insufficient.

That does not mean every grade 2 hemorrhoid requires a procedure. If symptoms settle with fibre, fluids and improved bowel habits, surgery may not be necessary.

Can grade 2 hemorrhoids be removed?

Yes. If a grade 2 hemorrhoid continues to cause bleeding or prolapse despite conservative treatment, a doctor may recommend an office procedure.

One commonly used option is rubber band ligation. A small band is placed around the base of the internal hemorrhoid, cutting off its blood supply. The treated tissue subsequently shrinks and separates. Other options can include sclerotherapy or coagulation techniques.

What is a grade 3 hemorrhoid?

A grade 3 hemorrhoid comes out through the anus during bowel movements or straining but does not return inside on its own.

The person usually needs to gently push the prolapsed tissue back inside.

Grade 3 hemorrhoids may cause:

• Recurrent bleeding
• Mucus discharge
• Itching
• Irritation
• Difficulty keeping the area clean
• A sensation of tissue coming out
• Discomfort during daily activities

Do grade 3 hemorrhoids go away?

They may improve symptomatically with better bowel habits, but persistent grade 3 prolapse may not disappear simply by changing your diet.

Selected patients with grade 3 hemorrhoids can be treated with office-based procedures. The ASCRS guidelines specifically recognise office treatment for selected grade III hemorrhoids that have not responded adequately to conservative treatment.

If the hemorrhoids are large, repeatedly prolapse, have a significant external component or continue to cause symptoms despite less-invasive treatment, surgery may be considered.

What is a grade 4 hemorrhoid?

A grade 4 hemorrhoid remains outside the anus and cannot be pushed back inside manually.

It is the most advanced category in the traditional internal hemorrhoid grading system. Persistent prolapse can cause irritation, bleeding, mucus discharge and difficulty maintaining hygiene.

Grade 4 hemorrhoids deserve medical assessment rather than repeated self-treatment.

Do grade 4 hemorrhoids need surgery?

Not every grade 4 hemorrhoid can be labelled as automatically requiring surgery, but grade 4 disease is much more likely to require a surgical assessment and definitive treatment.

The ASCRS guidelines recommend offering excisional hemorrhoidectomy to selected patients with symptomatic combined internal and external hemorrhoids in grades III–IV and selected patients with external hemorrhoids.

The final decision depends on factors such as:

• Size and extent of prolapse
• Internal versus external disease
• Bleeding
• Pain and irritation
• Previous treatments
• Recurrence
• Impact on daily life
• Overall health

A surgeon should assess the individual situation before recommending an operation.

Can I live with grade 4 hemorrhoids?

A person may live with grade 4 hemorrhoids for some time, particularly if symptoms are manageable. However, living with persistent prolapsed tissue without medical assessment is not advisable.

The tissue can remain irritated and difficult to clean, and bleeding or swelling may continue. In some cases, prolapsed hemorrhoidal tissue can become trapped or have its blood supply compromised.

If the tissue is permanently outside, painful, increasingly swollen or bleeding repeatedly, arrange an examination by a qualified doctor.

How long do grade 4 hemorrhoids take to go away?

There is no fixed number of days or weeks.

A permanently prolapsed grade 4 hemorrhoid may not return inside or disappear on its own, because grade 4 represents an irreducible prolapse. Lifestyle measures can improve constipation and reduce straining, but they may not reverse established prolapse.

When surgery is performed, the hemorrhoid is removed or treated during the procedure, but the surrounding tissues still need time to heal. Recovery after hemorrhoidectomy commonly takes around two to four weeks, although complete recovery can take longer depending on the procedure and individual circumstances.

Can grade 4 hemorrhoids be cancerous?

Hemorrhoids themselves are not cancer. A grade 4 hemorrhoid does not mean that you have cancer.

However, rectal bleeding should not automatically be blamed on hemorrhoids. Other conditions, including colorectal cancer, can also cause rectal bleeding. This is particularly important when bleeding is new, persistent, unexplained or accompanied by changes in bowel habits or stool appearance.

This is one reason a proper medical examination is important rather than relying solely on the appearance or presumed grade of piles.

At what stage should hemorrhoids be removed?

There is no single grade at which every patient must have hemorrhoids removed.

In general:

• Grade 1: Usually managed with dietary and bowel-habit changes.
• Grade 2: Often responds to conservative treatment; office procedures may be considered if symptoms persist.
• Grade 3: Some patients can have office-based treatment, while others may require surgery.
• Grade 4: More often requires specialist assessment and may require surgical treatment.

The ASCRS guidelines recommend dietary and behavioural changes as first-line treatment and support office-based procedures for most symptomatic grade I and II hemorrhoids and selected grade III cases. Excisional hemorrhoidectomy is typically offered to selected patients with symptomatic combined internal and external grade III–IV hemorrhoids.

So the decision should be based on symptoms and anatomy, not just the number attached to the grade.

Is grade 2 hemorrhoids serious?

Grade 2 hemorrhoids are generally not considered an emergency simply because they are grade 2. Many can be managed with lifestyle changes or office-based treatment.

However, persistent bleeding should not be ignored. Severe pain, heavy bleeding, dizziness, fainting, fever or rapidly worsening symptoms require prompt medical attention.

How many hours is hemorrhoid surgery?

The actual operation is usually much shorter than the entire hospital visit.

A conventional hemorrhoidectomy may take approximately 30 minutes to one hour, depending on the technique and complexity. Some procedures, such as hemorrhoidopexy, may take around 30–45 minutes.

The total time at the hospital will also include preparation, anaesthesia and recovery.

Many hemorrhoid procedures are performed as day surgery, although the exact arrangement depends on the procedure, medical history and surgeon’s recommendation.

What happens if I don’t remove a hemorrhoid?

Not every hemorrhoid needs to be removed.

A small or mildly symptomatic hemorrhoid may settle with conservative treatment. But persistent prolapsing hemorrhoids can continue to cause bleeding, irritation, mucus discharge, hygiene problems and discomfort.

More advanced disease can occasionally lead to complications such as thrombosis or strangulation. Significant chronic bleeding can also contribute to anaemia in some patients.

The important point is that “not removing” a hemorrhoid is not necessarily dangerous, but persistent or worsening symptoms should be evaluated so that the appropriate treatment can be selected.

What shrinks hemorrhoids fast?

There is no reliable home remedy that makes a significant hemorrhoid disappear instantly.

For mild hemorrhoids, the fastest way to improve symptoms is usually to address the factors that keep irritating them:

• Increase fibre gradually
• Drink enough fluids
• Avoid straining
• Keep stools soft
• Avoid prolonged toilet sitting
• Use warm sitz baths for discomfort
• Use appropriate topical medication when advised

For persistent internal hemorrhoids, treatments such as rubber band ligation, sclerotherapy or coagulation can physically reduce hemorrhoidal tissue by cutting off its blood supply or creating scarring.

Is hemorrhoid surgery worth it?

Whether hemorrhoid surgery is worthwhile depends on the individual case.

For someone with severe prolapse, large symptomatic hemorrhoids, recurrent problems or symptoms that have not responded to less-invasive treatments, surgery may provide substantial long-term relief.

On the other hand, someone with mild grade 1 or grade 2 hemorrhoids may have no reason to undergo surgery if conservative measures or an office procedure adequately control the symptoms.

Hemorrhoidectomy is effective, but recovery can involve significant temporary pain and requires careful attention to bowel movements and constipation prevention.

The right question is therefore not simply “Is surgery worth it?” but “What treatment is appropriate for the grade, symptoms and type of hemorrhoids I have?”

What’s the worst type of hemorrhoid?

In terms of the traditional internal hemorrhoid grading system, grade 4 is the most advanced grade of prolapse because the hemorrhoid remains outside and cannot be pushed back in.

However, “worst” does not necessarily mean “most painful.” The grade mainly describes prolapse. A thrombosed external hemorrhoid, for example, can be extremely painful even though the traditional grade 1–4 internal hemorrhoid system does not apply to it.

What size hemorrhoids need surgery?

There is no universal size in centimetres that means a hemorrhoid must be surgically removed.

This is an important distinction because hemorrhoid grade is primarily based on prolapse behaviour, not a specific measurement of size.

A doctor considers the size and location of the hemorrhoids, whether they are internal or external, how much they prolapse, how often they bleed, whether they recur and whether non-surgical treatments have worked.

Large symptomatic hemorrhoids or significant combined internal and external disease are more likely to require surgical treatment.

What foods should I avoid with hemorrhoids?

There is no universal “hemorrhoid food” that everyone must completely eliminate. The main dietary goal is to prevent constipation and hard stools.

It may help to limit foods and eating patterns that contribute to constipation or aggravate your individual symptoms. Depending on the person, this can include:

• Highly processed, low-fibre foods
• Large amounts of refined carbohydrates
• Excessive fried or highly fatty foods if they worsen digestive symptoms
• Excessive alcohol
• Very spicy foods if they cause burning or irritation

Instead, focus on fibre-rich foods such as:

• Fruits
• Vegetables
• Whole grains
• Pulses and legumes
• Oats
• Fibre-rich cereals
• Nuts and seeds

Increase fibre gradually and drink enough fluid. Fibre helps make stools softer and easier to pass, reducing the need to strain.

How are hemorrhoids diagnosed?

A doctor generally begins with your symptoms and bowel history, followed by an examination.

Depending on the situation, assessment may include:

• Examination of the anal area
• Digital rectal examination
• Anoscopy or another examination of the anal canal
• Further bowel evaluation when clinically indicated

This is important because rectal bleeding can have causes other than hemorrhoids.

When should you see a doctor for hemorrhoids?

Consider seeing a doctor if:

• Rectal bleeding keeps recurring
• Symptoms last despite home treatment
• A lump repeatedly comes out of the anus
• You need to manually push the tissue back
• Tissue remains outside the anus
• Pain is significant or worsening
• You have difficulty cleaning the area
• You develop heavy bleeding
• You experience dizziness, fainting or weakness

Seek urgent medical attention for severe anal pain with significant bleeding, particularly when accompanied by fever, abdominal symptoms or other concerning symptoms.

Frequently asked questions about hemorrhoid grades

What is a grade 1, 2, 3, 4 hemorrhoid?

Grade 1 hemorrhoids stay inside the anal canal. Grade 2 come out during bowel movements but return inside by themselves. Grade 3 come out and need to be pushed back manually. Grade 4 remain outside and cannot be pushed back inside.

Do grade 4 hemorrhoids need surgery?

Not every patient is automatically sent for surgery, but grade 4 hemorrhoids are more likely to require specialist assessment and surgical treatment, particularly when they are symptomatic or associated with external hemorrhoidal disease.

Can grade 2 hemorrhoids be removed?

Yes. Persistent grade 2 hemorrhoids can be treated with procedures such as rubber band ligation, sclerotherapy or coagulation. Surgery is not automatically required.

Do grade 3 hemorrhoids go away?

Symptoms may improve, but persistent grade 3 prolapse may require an office procedure or surgery. Selected grade 3 hemorrhoids can be treated with office-based procedures.

Can a grade 2 hemorrhoid go away without surgery?

Yes. Improving constipation, increasing fibre, drinking adequate fluids and avoiding straining may control symptoms. If symptoms persist, an office procedure may be considered.

Can I live with grade 4 hemorrhoids?

You may live with them for some time, but persistent grade 4 prolapse should be assessed by a doctor because it can cause ongoing irritation, bleeding, hygiene difficulties and complications.

How long do grade 4 hemorrhoids take to go away?

There is no fixed timeframe. A permanently prolapsed grade 4 hemorrhoid may not return inside on its own. When treated surgically, healing commonly takes several weeks.

Can grade 4 hemorrhoids be cancerous?

Hemorrhoids are not cancer. However, rectal bleeding should be properly evaluated because cancers and other bowel conditions can also cause bleeding.

At what stage should hemorrhoids be removed?

There is no single grade that automatically requires removal. Treatment depends on symptoms, prolapse, size, internal or external involvement and response to conservative or office-based treatment.

Is grade 2 hemorrhoids serious?

Grade 2 hemorrhoids are often manageable and are not automatically serious. Persistent bleeding or worsening symptoms should still be assessed.

How many hours is hemorrhoid surgery?

The actual surgery commonly takes about 30 minutes to one hour, depending on the procedure and complexity. The entire hospital visit will be longer because of preparation and recovery.

What happens if I don’t remove a hemorrhoid?

Some hemorrhoids settle without removal. Persistent advanced hemorrhoids, however, may continue to prolapse, bleed or cause irritation and can occasionally develop complications.

What shrinks hemorrhoids fast?

Fibre, fluids and avoiding straining help control the underlying problem but do not instantly eliminate hemorrhoids. Persistent internal hemorrhoids may shrink after procedures such as rubber band ligation or sclerotherapy.

Is hemorrhoid surgery worth it?

It depends on your symptoms and the type of hemorrhoids. Surgery may be appropriate for severe, recurrent or prolapsing hemorrhoids that have not responded adequately to less-invasive treatment.

What’s the worst type of hemorrhoid?

Grade 4 is the most advanced grade in terms of internal hemorrhoid prolapse. However, grade does not directly measure pain.

What size hemorrhoids need surgery?

There is no specific size threshold. The decision depends on prolapse, symptoms, internal or external involvement, recurrence and response to other treatments.

What foods should I avoid with hemorrhoids?

There is no universal banned-food list. Focus on a high-fibre diet and adequate fluids, and reduce foods that contribute to constipation or personally worsen digestive or anal irritation.

The bottom line

Understanding hemorrhoid grades can make a diagnosis much less confusing.

Grade 1: stays inside.
Grade 2: comes out but returns by itself.
Grade 3: comes out and needs to be pushed back.
Grade 4: stays outside and cannot be pushed back.

A higher grade does not automatically mean more pain, more bleeding or cancer. It primarily tells a doctor about the degree of internal hemorrhoid prolapse. Treatment ranges from fibre, fluids and bowel-habit changes to office procedures and, for selected patients with advanced or persistent disease, surgery.

Most importantly, do not assume that every episode of rectal bleeding is caused by piles. Persistent or unexplained bleeding deserves medical evaluation.

If you are experiencing recurrent bleeding, a lump coming out during bowel movements, tissue that remains outside the anus, significant pain or symptoms that are affecting your daily life, consult a qualified doctor for an examination and an appropriate treatment plan.