Haemorrhoids: Grades 1 to 4 What They Mean and Which Needs Surgery
A guide for patients in Campbelltown and South Western Sydney
General information only: This article provides general educational information about haemorrhoid grading and treatment. It does not replace assessment or personalised advice from your GP or surgeon. Rectal bleeding should always be assessed by a doctor — do not assume bleeding is from haemorrhoids without medical review, particularly in adults over 40 or those with other symptoms. |
Haemorrhoids — More Common Than Most People Realise
Haemorrhoids — commonly called piles — are one of the most prevalent conditions affecting adults in Australia. It is estimated that up to 75% of people will experience haemorrhoids at some point in their life. Despite how common they are, many patients delay seeking assessment due to embarrassment, or assume their symptoms will resolve on their own without treatment.
Not all haemorrhoids are the same. They range from small internal swellings that cause no discomfort and resolve with dietary changes, through to large prolapsing haemorrhoids that cause significant pain, bleeding and impact on daily life and require surgical treatment. Understanding which grade of haemorrhoid you have is the first step in understanding which treatment is appropriate.
Dr Devesh Kaushal is a specialist general surgeon at 4 Hyde Parade, Campbelltown, who assesses and treats haemorrhoids across the full range of grades for patients across South Western Sydney.
Haemorrhoid Assessment and Treatment — Campbelltown Contact the rooms to discuss current availability | (02) 7906 8312 | drdeveshkaushal.com.au |
What Are Haemorrhoids?
Haemorrhoids are clusters of vascular tissue — blood vessels, connective tissue and smooth muscle — found naturally in the anal canal and lower rectum. In their normal state, these vascular cushions play a role in fine-tuning anal continence, helping to seal the anal canal.
Haemorrhoids become a medical problem when these vascular cushions enlarge, become congested, or prolapse — sliding downward through the anal canal. When this happens, they cause symptoms including bleeding, prolapse, discomfort, mucus discharge and skin irritation around the anus.
Internal vs External haemorrhoids:
Internal Haemorrhoids | External Haemorrhoids |
• Arise above the dentate line inside the anal canal • Covered by mucosa — no pain receptors • Typically cause painless bright red bleeding • May prolapse out of the anal canal • Graded using the 4-grade classification system | • Arise below the dentate line at the anal verge • Covered by skin — contain pain receptors • Usually visible as a lump around the anus • Cause pain particularly when thrombosed • Not graded — managed differently from internal haemorrhoids |
The grading system described in this article applies to internal haemorrhoids. External haemorrhoids are not graded — they are managed based on their symptoms, size and whether thrombosis (clotting) has occurred. Many patients have both internal and external haemorrhoids simultaneously. |
What Causes Haemorrhoids?
Haemorrhoids develop when increased pressure in the lower rectum and anal canal causes the vascular cushions to engorge and — over time — slide downward. Common contributing factors include:
- Chronic constipation and straining at stool — the most common cause. Repeated Valsalva manoeuvre increases pressure in the haemorrhoidal vessels
- Prolonged sitting on the toilet
- Chronic diarrhoea — repeated loose stools irritate and inflame the anal tissue
- Low-fibre diet — produces hard, difficult-to-pass stools
- Pregnancy — increased intra-abdominal pressure and pelvic venous congestion
- Obesity — increased intra-abdominal pressure
- Sedentary lifestyle — reduced bowel motility and increased pelvic venous pressure
- Ageing — weakening of the connective tissue supporting the haemorrhoidal cushions
Heavy lifting — sustained increases in intra-abdominal pressure
The 4 Grades of Internal Haemorrhoids — Explained
Internal haemorrhoids are classified using the Goligher grading system — a four-grade scale based on the degree of prolapse. Grade determines both the severity of the condition and the most appropriate treatment approach. This grading is determined by a surgeon on examination and, where indicated, proctoscopy.
I Grade 1 | No prolapse — haemorrhoids remain inside the anal canal at all times Features: Painless bright red bleeding, typically noticed on toilet paper or in the toilet bowl. No visible or palpable lump. No prolapse. Often discovered at proctoscopy performed for other reasons. Treatment: Conservative management — high-fibre diet, adequate fluid intake, avoid straining, stool softeners if needed. Topical preparations for symptom relief. No procedural intervention usually required. |
II Grade 2 | Prolapse on straining — reduces spontaneously Features: Bleeding with defecation. Haemorrhoids prolapse through the anal canal during straining or defecation but reduce spontaneously without manual assistance when straining ceases. Mucus discharge and perianal itch may occur. Treatment: Conservative measures first. Rubber band ligation (RBL) is the most commonly used office procedure for Grade II haemorrhoids and is generally the preferred first-line procedural treatment. Sclerotherapy is an alternative. |
III Grade 3 | Prolapse on straining — requires manual reduction Features: Haemorrhoids prolapse with defecation or straining and do not reduce spontaneously — they must be manually pushed back by the patient. Mucus discharge, soiling, perianal irritation and discomfort are common. Bleeding may be significant. Treatment: Rubber band ligation may be trialled, particularly for smaller Grade III haemorrhoids. Surgical haemorrhoidectomy is frequently recommended for Grade III haemorrhoids, particularly those that are large, symptomatic or have not responded to banding. Haemorrhoid artery ligation (HAL/HALO) may be appropriate in selected cases. |
IV Grade 4 | Permanent prolapse — cannot be reduced Features: Haemorrhoids remain prolapsed at all times and cannot be returned to the anal canal by manual reduction. Include acutely thrombosed prolapsed haemorrhoids. Associated with significant discomfort, soiling, mucus discharge and bleeding. Strangulation may occur. Treatment: Surgical haemorrhoidectomy is the standard treatment for Grade IV haemorrhoids. Emergency haemorrhoidectomy may be required for acutely thrombosed prolapsed Grade IV haemorrhoids in selected circumstances. |
Grade at a Glance — Quick Reference
Grade | Prolapse | Main Symptom | Typical Treatment |
I | None | Bleeding only | Diet and lifestyle, topical treatment |
II | Prolapse — reduces spontaneously | Bleeding, mucus, itch | Rubber band ligation, sclerotherapy |
III | Prolapse — needs manual reduction | Prolapse, soiling, discomfort | Banding (selected) or haemorrhoidectomy |
IV | Permanent prolapse | Constant prolapse, significant discomfort | Surgical haemorrhoidectomy |
Symptoms of Haemorrhoids — What to Look For
The symptoms of haemorrhoids vary depending on the grade and whether haemorrhoids are internal, external or mixed. The most common symptoms include:
- Bright red rectal bleeding: The most common presenting symptom. Typically painless, noticed on toilet paper, in the toilet bowl, or on the surface of the stool. The blood is bright red — not dark or mixed through the stool.
- Prolapse: A lump or tissue appearing at the anus during or after defecation. In Grade II it reduces spontaneously; Grade III requires manual reduction; Grade IV remains prolapsed.
- Perianal itch and irritation: Mucus discharge from prolapsed haemorrhoids irritates the perianal skin, causing persistent itching and discomfort.
- Mucus discharge: Mucus-producing mucosa of prolapsed haemorrhoids secretes mucus that can cause soiling of underwear and perianal skin irritation.
- Discomfort or pressure: A feeling of incomplete emptying, heaviness or pressure in the rectum — particularly with Grade III and IV haemorrhoids.
- Pain: Internal haemorrhoids above the dentate line do not typically cause pain unless they become acutely thrombosed or strangulated. External haemorrhoids and thrombosed haemorrhoids cause significant pain.
⚠ See your GP promptly — do not assume symptoms are haemorrhoids: • Blood mixed through the stool or dark red/maroon blood — not just on toilet paper • Rectal bleeding with unexplained weight loss or change in bowel habit • Rectal bleeding in a person aged over 40 without prior investigation • Persistent bleeding that does not settle Haemorrhoids and colorectal cancer can produce similar-appearing rectal bleeding. Clinical assessment — and colonoscopy where indicated — is necessary to exclude a serious cause. Do not assume bleeding is haemorrhoidal without medical review. |
Conservative Management — Treating Haemorrhoids Without Procedures
For Grade I haemorrhoids, and as a first-line approach for Grade II, conservative management addresses the underlying factors contributing to haemorrhoid development and provides symptom relief. Conservative measures should be tried consistently before procedural intervention is considered in lower-grade haemorrhoids.
Dietary and lifestyle measures:
- Increase dietary fibre to 25 to 30 grams per day — fruit, vegetables, legumes, whole grains, psyllium husk. Adequate fibre produces soft, bulky stools that pass without straining.
- Increase fluid intake — 6 to 8 glasses of water daily prevents hard stools
- Avoid prolonged sitting on the toilet — use the toilet only when the urge to defecate is present. Do not read or use a phone on the toilet.
- Do not strain or push hard during defecation
- Regular physical activity — improves bowel motility and reduces pelvic venous congestion
- Warm sitz baths — sitting in warm water for 10 to 15 minutes several times daily reduces discomfort and perianal inflammation
Topical preparations:
A range of over-the-counter topical creams, ointments and suppositories are available for haemorrhoid symptom relief. These typically contain combinations of local anaesthetic, astringent, anti-inflammatory or vasoconstrictor agents. They provide symptomatic relief — reducing pain, itch and swelling — but do not treat the underlying haemorrhoids or reduce their grade. They should not be used for more than 7 to 10 days without medical advice.
Stool softeners:
Where constipation is contributing to symptoms, a short course of stool softeners or osmotic laxatives may be recommended by your GP to reduce straining while dietary fibre intake is increased.
Office-Based Procedures — Between Conservative and Surgical
For Grade II haemorrhoids — and selected Grade III cases — office-based procedures offer an effective treatment without the need for general anaesthesia or surgery. The two most commonly used are rubber band ligation and sclerotherapy.
Rubber band ligation (RBL):
Rubber band ligation is the most widely used and generally most effective office procedure for internal haemorrhoids. A small elastic band is applied to the base of the haemorrhoid using a proctoscope — cutting off its blood supply. The haemorrhoid shrinks and falls off within 5 to 10 days, with a small wound that heals over. Dr Kaushal performs rubber band ligation in hospital under anaesthesia. You will not be able to drive yourself home after the procedure. A responsible adult must be available to take you home. Mild discomfort or a pressure sensation is common for 24 to 48 hours afterwards. One to three haemorrhoids may be banded per session, with sessions spaced 4 to 6 weeks apart if multiple sessions are needed.
Sclerotherapy:
A chemical solution is injected into the base of the internal haemorrhoid, causing it to shrink by sclerosis (fibrosis). Less commonly used than banding in current practice, but may be appropriate for patients on anticoagulation therapy where banding carries a higher bleeding risk, or for Grade I to II haemorrhoids where banding is not technically straightforward.
Office procedures are not appropriate for all haemorrhoids: Rubber band ligation and sclerotherapy are appropriate for internal haemorrhoids at the correct grade. They are not effective for external haemorrhoids, thrombosed haemorrhoids, or large Grade III–IV prolapsing haemorrhoids. The appropriate procedure is determined at clinical assessment. |
Surgical Treatment — When Is Surgery Needed?
Surgical haemorrhoidectomy is the definitive treatment for haemorrhoids that have not responded to conservative management and office-based procedures, or that are too large or prolapsed to be managed with these approaches. Surgery is generally recommended for Grade III haemorrhoids that have failed banding and for Grade IV haemorrhoids.
Conventional haemorrhoidectomy:
The haemorrhoidal tissue is surgically excised under general or spinal anaesthesia. The procedure may be performed as open haemorrhoidectomy (Milligan-Morgan technique — wounds left open to heal) or closed haemorrhoidectomy (Ferguson technique — wounds sutured closed). Both techniques have well-established outcomes. Haemorrhoidectomy provides the most durable long-term results of any haemorrhoid treatment and has the lowest recurrence rate.
Stapled haemorrhoidopexy (PPH):
A circular stapling device repositions and fixes prolapsing haemorrhoidal tissue above the dentate line rather than excising it. Associated with less post-operative pain than conventional haemorrhoidectomy in the early period, but higher recurrence rates and risk of prolapse recurrence — particularly for large Grade III–IV haemorrhoids. Used in selected cases.
Haemorrhoidal artery ligation (HAL/HALO):
Doppler-guided identification and ligation of the haemorrhoidal feeding arteries reduces blood supply to the haemorrhoidal cushions, causing them to shrink. Can be combined with mucopexy (suture fixation of prolapsing tissue). Less painful than haemorrhoidectomy. Best suited to Grade II–III haemorrhoids without large external components.
Procedure | Grade | Anaesthesia | Key Point |
Rubber band ligation | I–II (selected III) | General anaesthesia — day procedure | Most commonly used outpatient procedure. Multiple sessions may be needed. |
Sclerotherapy | I–II | General anaesthesia — day procedure | Alternative to banding — useful for patients on anticoagulation. |
HAL / HALO | II–III | General or spinal | Less painful recovery. Higher recurrence than haemorrhoidectomy for large haemorrhoids. |
Stapled haemorrhoidopexy (PPH) | III (selected) | General or spinal | Less early pain but higher recurrence risk than conventional haemorrhoidectomy. |
Conventional haemorrhoidectomy | III–IV | General or spinal | Most durable result. Lowest long-term recurrence. Standard surgical treatment. |
Recovery After Haemorrhoid Surgery
Recovery after haemorrhoidectomy is one of the more uncomfortable surgical recoveries in general surgery — the anal region is richly supplied with nerve endings, and post-operative pain can be significant. Understanding what to expect helps patients prepare and comply with pain management measures.
Timeframe | What to Expect |
Day of surgery | Day surgery in most cases — home same day. Significant anal pain and discomfort — managed with prescribed analgesia including regular paracetamol, anti-inflammatories and in the early period, opioid pain relief. A sitz bath on day 1 helps. |
Days 1–5 | Pain with bowel motions is the most significant challenge. Stool softeners are prescribed to avoid hard stools — use them consistently. Warm sitz baths (10–15 minutes, 3 times daily) reduce pain and promote wound healing. Expect some bleeding — small amounts of bright red blood with bowel motions are expected. |
Days 5–14 | Pain gradually improving. Continue stool softeners and sitz baths. Avoid constipation — contact the rooms if bowels have not opened by day 3 to 4 post-surgery. Light activity only. |
Weeks 2–4 | Most patients are considerably more comfortable. Return to desk work typically possible from week 2. Physical work and strenuous activity deferred to week 4 to 6. |
Weeks 4–6 | Most patients cleared for full activity. Wound healing is usually complete. A small amount of spotting with bowel motions can persist for several weeks as the wounds fully heal. |
Full healing | Complete wound healing typically occurs by 6 to 8 weeks. Dietary measures — adequate fibre and fluid — should be maintained long-term to prevent haemorrhoid recurrence. |
Pain management after haemorrhoidectomy: The first bowel motion after haemorrhoidectomy is typically the most difficult. Take prescribed pain relief 30 to 45 minutes before you anticipate a bowel motion. Warm sitz baths immediately after each bowel motion provide significant relief. Do not avoid going to the toilet — holding on leads to harder stools and worse pain. |
Frequently Asked Questions
How do I know what grade my haemorrhoids are?
Haemorrhoid grading is determined by a surgeon or colorectal specialist on the basis of clinical history and physical examination, including proctoscopy — a brief examination of the anal canal with a small lighted instrument. You cannot reliably self-grade haemorrhoids. If you have symptoms of haemorrhoids — particularly rectal bleeding — a GP assessment and, where indicated, a referral to a specialist is the appropriate first step.
Can Grade III or IV haemorrhoids go back to Grade I or II with conservative treatment?
Conservative treatment — dietary fibre, fluid, avoiding straining, stool softeners and sitz baths — can reduce symptoms and inflammation significantly, and may make haemorrhoids less symptomatic. However, established Grade III and IV haemorrhoids with significant prolapse do not reliably return to a lower grade with conservative measures alone. Procedural or surgical intervention is typically required to achieve lasting improvement in higher-grade haemorrhoids.
Is haemorrhoid surgery painful?
Haemorrhoidectomy is associated with significant post-operative pain — more so than many other surgical procedures of similar complexity — due to the dense nerve supply of the anal region. This is well recognised and patients are prescribed comprehensive pain management including regular paracetamol, anti-inflammatory medication, local anaesthetic agents, and short-term opioid analgesia where needed. Warm sitz baths provide meaningful relief. Pain improves progressively over 1 to 2 weeks, though complete comfort with bowel motions may take 4 to 6 weeks.
Will haemorrhoids come back after surgery?
Conventional haemorrhoidectomy has the lowest long-term recurrence rate of any haemorrhoid treatment. Recurrence can occur — particularly if the underlying dietary and lifestyle factors that caused haemorrhoids are not addressed after surgery. Maintaining a high-fibre diet, adequate fluid intake, avoiding straining, and not spending excessive time on the toilet are the most important measures to reduce recurrence risk after surgery.
I have been told I need surgery but I am worried — can I ask for a second opinion?
Yes — you are always entitled to seek a second surgical opinion before proceeding with any elective operation. A specialist assessment is required to confirm the haemorrhoid grade and confirm that surgery is the appropriate recommendation for your individual situation. If you have been told you need haemorrhoid surgery and would like an assessment with Dr Kaushal at Campbelltown, contact the rooms with your GP referral.
Haemorrhoid Assessment in Campbelltown
If you have symptoms of haemorrhoids and would like a specialist assessment — or have been referred for haemorrhoid treatment — contact Dr Kaushal’s rooms at 4 Hyde Parade, Campbelltown. A GP referral is recommended and required for Medicare rebates.
Specialist General Surgeon | Upper GI and Bariatric Surgery 4 Hyde Parade, Campbelltown NSW 2560 Phone: (02) 7906 8312 Email: [email protected] | drdeveshkaushal.com.au Office Hours: Monday – Friday, 9:00 AM – 5:00 PM Current hospital appointments and accreditations include: Sydney Southwest Private Hospital Liverpool | Campbelltown Public Hospital | Campbelltown Private Hospital | The George Hospital Medicare rebates and private health insurance benefits may apply depending on the service, referral and individual policy. Please contact the rooms and your insurer regarding fees and potential out-of-pocket costs. |
General information only: This article provides general educational information about haemorrhoid grading and treatment. It does not replace assessment or personalised advice from your GP or surgeon. Rectal bleeding should always be assessed by a doctor — do not assume bleeding is haemorrhoidal without medical review. |