Hemorrhoid Grades Explained: What Grade 4 Hemorrhoids Mean For Treatment

Hearing the words grade 4 hemorrhoids can be unsettling, but the grade is mostly a way for doctors to describe how far internal hemorrhoids have slipped and which treatments are likely to work. Understanding the scale helps you make sense of what your doctor says and ask better questions.

This guide explains the grading system from 1 to 4, what makes a hemorrhoid grade 4, what complications to watch for, and how treatment usually fits each grade. It reflects how the pharmacists at South Fork Pharmacy in Moorefield, WV explain it to customers who have just come back from a doctor’s visit.

How Hemorrhoids Are Graded

The most widely used system is the Goligher classification, and it applies to internal hemorrhoids, the ones inside the rectum. It is based on one thing: how far the hemorrhoid prolapses, or slips down and out of the anus, and whether it goes back in.

Grade 1 hemorrhoids bulge into the anal canal but do not come out. They often cause painless bleeding and little else. Grade 2 hemorrhoids come out during a bowel movement but go back in on their own afterward. Grade 3 hemorrhoids come out and have to be pushed back in by hand. Grade 4 hemorrhoids are out and stay out, and they cannot be pushed back in, or they slip right back out if you try.

External hemorrhoids, the ones under the skin at the anal edge, are not graded this way. Doctors describe them by size, whether they have a clot, and how much they bother you. Many people have both internal and external hemorrhoids at the same time, which is called mixed hemorrhoids.

Grading is a clinical assessment. It usually involves a visual exam and often a short scope called an anoscope. It is not something you can do reliably at home, because swelling, external hemorrhoids, skin tags, and other conditions such as rectal prolapse can look similar. If you think you have a hemorrhoid that will not go back in, the next step is an exam.

It is also worth knowing that the grade describes the hemorrhoid at the time of the exam. Hemorrhoids can move between grades. A grade 2 hemorrhoid can progress to grade 3 with years of straining, and a swollen grade 3 hemorrhoid during a bad flare can look like grade 4 until the swelling settles. That is one reason a doctor may want to see you again before recommending surgery.

The grade also does not tell the whole story about how much a hemorrhoid bothers you. Some people with grade 2 hemorrhoids have frequent bleeding and real discomfort, while some with grade 3 have few complaints. Doctors weigh both the grade and your symptoms when recommending treatment.

What Makes A Hemorrhoid Grade 4

A grade 4 hemorrhoid is permanently prolapsed. The internal hemorrhoidal tissue has slipped down past the anal opening and stays there, either because the supporting tissue has stretched too far or because swelling keeps it from going back. Attempts to push it back in do not work, or it comes right back out.

Because the tissue is outside, it is exposed to friction from clothing and wiping. The lining of internal hemorrhoids is meant to stay moist and inside the body, so outside it can become irritated, produce mucus, and bleed. Many people feel a constant lump, pressure, or the sense that something is always there.

Grade 4 hemorrhoids often develop gradually from lower grades over months or years, especially with long-term constipation and straining. They are more common in older adults, since the connective tissue that holds hemorrhoids in place weakens with age. Some people also have external hemorrhoids and skin tags around the same area, which can make the picture more complex.

It is worth repeating that only a doctor can confirm a grade 4 hemorrhoid. A rectal prolapse, where the wall of the rectum itself slips out, can look similar and needs different treatment. A thrombosed external hemorrhoid can also feel like a lump that will not go back in. An exam sorts these out.

Symptoms And Complications At Grade 4

Common symptoms include a persistent lump or bulge at the anus, discomfort when sitting or walking, bleeding, mucus discharge, itching from moisture, and difficulty keeping the area clean. Some people notice small amounts of stool leakage because the prolapsed tissue interferes with the seal of the anus.

Bleeding from grade 4 hemorrhoids can be ongoing, and over time even modest bleeding can lead to anemia, causing tiredness, weakness, or shortness of breath. That is one reason doctors take grade 4 hemorrhoids seriously even when they are not very painful.

The most important complication is strangulation. This happens when the muscles around the anus squeeze a prolapsed hemorrhoid and cut off its blood supply. The hemorrhoid becomes very painful, swollen, and may turn dark purple or black. Thrombosis, where blood clots inside the prolapsed tissue, can cause similar sudden, severe pain. Both need prompt medical care.

Other complications include infection, skin breakdown around the area, and, rarely, tissue death if strangulation is not treated. These are uncommon, but they are the reason sudden severe pain, fever, or a hemorrhoid that changes color should never be waited out at home.

Grade By Grade: Which Treatment Usually Fits

Many articles explain the grades and then jump straight to surgery for grade 4. What is often missing is a side-by-side view of how treatment usually changes from one grade to the next, which helps you understand why your doctor recommends what they do. This is a general picture, and your doctor’s advice for your situation comes first.

For grade 1, treatment usually starts with fiber, fluids, and better bowel habits, along with OTC products for symptom relief. If bleeding continues, an office procedure such as rubber band ligation, sclerotherapy, or infrared coagulation may be offered. For grade 2, the same lifestyle steps apply, and office procedures, especially rubber band ligation, are commonly used if symptoms persist.

For grade 3, rubber band ligation is often still the first procedure tried, sometimes over several sessions. If that does not work, or if the hemorrhoids are large, surgery such as hemorrhoidectomy, stapled hemorrhoidopexy, or hemorrhoidal artery ligation may be discussed. For grade 4, surgery is usually the main recommendation. Some small studies have looked at staged banding for grade 4, but hemorrhoidectomy remains the standard reference treatment in most guidelines.

Useful questions to ask your doctor include: What grade are my hemorrhoids, and are they internal, external, or both? Is an office procedure an option for me, or do you recommend surgery? What is the recovery like, and how much time off will I need? What are the chances they come back? What should I do in the meantime for comfort? In South Fork Pharmacy’s experience, people who leave with answers to those questions feel far more in control of the decision.

Your overall health also shapes the plan. People who take blood thinners, have heart or lung disease, or have other conditions that make anesthesia riskier may be offered a different approach than someone in good general health. Be sure your doctor has a full list of your medicines, and do not stop any prescription, including a blood thinner, unless your doctor tells you to.

Treatment Options For Grade 4

Hemorrhoidectomy, the surgical removal of hemorrhoidal tissue, is the most established treatment for grade 4 hemorrhoids. It has the lowest rate of recurrence. The tradeoff is recovery: pain for one to two weeks or more is common, and full recovery can take several weeks. Your surgeon will discuss pain control, stool softeners, and sitz baths for that period.

Other surgical options may be offered depending on the situation. Stapled hemorrhoidopexy lifts the prolapsed tissue back into place and reduces its blood supply, usually with less pain afterward but a somewhat higher chance of recurrence. Hemorrhoidal artery ligation uses ultrasound guidance to tie off the arteries feeding the hemorrhoids, sometimes combined with a stitch to lift the tissue. Laser procedures are available at some centers. Your surgeon will recommend what fits your anatomy and health.

OTC products have a supporting role only. Protectant ointments, witch hazel pads, lidocaine products, and short courses of hydrocortisone cream can ease irritation, itching, and pain while you arrange care or recover. They will not shrink a grade 4 hemorrhoid or make it go back in. Hydrocortisone should not be used for more than seven days for hemorrhoids without a doctor’s advice.

Lifestyle steps still matter before and after treatment. Soft stools, plenty of fluids, and avoiding straining make surgery recovery easier and reduce the chance of new hemorrhoids forming later. A stool softener or fiber supplement is commonly recommended after surgery, and your surgeon will tell you which to use.

When To Stop Self-Treating And Call A Doctor

If you think you may have hemorrhoids that stay outside and will not go back in, see a doctor rather than relying on OTC products. Call promptly if bleeding is heavy or keeps coming back, if symptoms have not improved within about seven days, or if pain is severe.

Seek same-day care if a prolapsed hemorrhoid suddenly becomes very painful, swollen, or dark in color, or if you have fever, spreading redness, or trouble passing urine. Also call if you notice changes in bowel habits that last more than a few days, or dark, maroon, or black stool. Dizziness or weakness with bleeding needs urgent attention.

Our pharmacy services team can help you prepare for your appointment and recovery, and our medication information library explains the comfort products mentioned here.

Frequently Asked Questions

Can grade 4 hemorrhoids go away without surgery?

It is uncommon. OTC products and lifestyle changes can ease symptoms, but most grade 4 hemorrhoids need a procedure to resolve, so talk with your doctor about options.

How do I know if my hemorrhoid is grade 4?

You cannot know for sure at home, because other conditions can look similar. A doctor grades hemorrhoids during an exam.

Is grade 4 hemorrhoid surgery very painful?

Recovery after hemorrhoidectomy is often uncomfortable for one to two weeks or more. Your surgeon will give you a plan for pain control, stool softeners, and sitz baths.

Is stage 4 the same as grade 4 or fourth degree hemorrhoids?

Yes, these terms are used interchangeably. They all describe internal hemorrhoids that stay outside and cannot be pushed back in.

What can I use for comfort until I see the doctor?

Warm sitz baths, protectant ointments, witch hazel pads, and soft stools may help. The pharmacists at South Fork Pharmacy can help you choose products that fit your health and medicines.

When is a prolapsed hemorrhoid an emergency?

Seek care right away if it becomes suddenly very painful, swollen, or dark in color, or if you have fever. Those can be signs that its blood supply is trapped.