Introduction
One of the first things a colorectal surgeon will want to work out is: what grade are your haemorrhoids? This isn't a minor technical detail — it shapes your entire treatment pathway. Grade I haemorrhoids are managed with diet and topical creams. Grade IV almost always needs surgery. The grades in between come with a range of options, and understanding where you sit helps make sense of why your doctor is recommending what they are.
It's worth knowing that grading applies specifically to internal haemorrhoids — those that develop above the dentate line (a natural boundary inside the anal canal, roughly where sensitive skin meets the lining of the bowel). External haemorrhoids (the ones outside the anal opening, covered in skin) are assessed differently — mainly by size and whether they've become thrombosed (developed a painful blood clot inside them). This article focuses on the internal grading system, since that's what guides most treatment decisions.
What are haemorrhoids?
Haemorrhoids are actually a normal part of your anatomy — they're cushions of tissue (containing blood vessels, smooth muscle, and connective tissue) that sit inside the anal canal. They help with fine continence control and create a comfortable seal. They only become a problem when they enlarge, slide downward (prolapse), or start bleeding.
Internal haemorrhoids develop above the dentate line, in tissue that doesn't have pain-sensing nerves. That's why internal haemorrhoids are usually painless — even when they're actively bleeding, the tissue itself can't feel it. Pain typically only comes if they prolapse significantly and become strangulated (the blood supply gets cut off), or if there's an external component involved as well.
Symptoms by grade
Symptoms vary quite a bit depending on the grade. Here's what each stage typically feels like — and what it means for treatment.
Bleeding without prolapse
Grade I haemorrhoids bleed — you might see bright red blood on the toilet paper or in the bowl — but they don't protrude outside the anal canal at any point. Many people have Grade I haemorrhoids without realising it until a colonoscopy or proctoscopy (a short examination with a small scope) picks them up. Bleeding tends to be intermittent, brought on by firm stools or straining.
Prolapse that goes back in on its own
Grade II haemorrhoids slip out (prolapse) through the anus when you strain during a bowel motion, but then go back inside on their own without you needing to do anything. You might feel a soft lump briefly after passing a motion, then notice it's gone. Mucous discharge, itching, and a feeling of not having fully emptied become more common at this stage.
Prolapse you need to push back in
Grade III haemorrhoids prolapse and don't go back in on their own — you need to push them back with your finger. Most people at this grade notice prolapse during and after every bowel motion. You may also have mucous staining on your underwear, persistent itching around the back passage, and increasing discomfort. Interestingly, visible bleeding can actually become less prominent at this stage as the tissue becomes more fibrous.
Permanently prolapsed
Grade IV haemorrhoids stay outside the anal canal all the time and can't be pushed back in. This category also includes acutely thrombosed prolapsed haemorrhoids (where a blood clot has formed). Symptoms at this grade are usually significant — a constant awareness of tissue outside the back passage, difficulty keeping clean, mucous discharge, skin irritation, and sometimes quite significant pain if strangulation or thrombosis has occurred.
Causes and progression
Haemorrhoids tend to get worse over time if the underlying causes aren't addressed. The usual culprits are chronic straining, a low-fibre diet, hard stools, and spending a long time sitting on the toilet. Pregnancy can cause rapid progression — the increased pressure in the pelvis, combined with hormonal changes that loosen connective tissue, can accelerate things quite quickly. Age is also a factor: the supportive tissue in the anal canal becomes less elastic as we get older, which makes prolapse more likely.
That said, progression from Grade I to Grade IV is not inevitable. Addressing the contributing factors — especially keeping stools soft and avoiding straining — can genuinely slow things down, and sometimes allows lower-grade haemorrhoids to settle.
When to worry
Any new rectal bleeding should be checked by a doctor — please don't assume it's haemorrhoids without getting it assessed. Regardless of grade, see your GP sooner rather than later if:
- Bleeding is heavy, or the blood is mixed through the stool rather than just on the surface
- You're over 40 and this is new
- There's also a change in your bowel habits, unexplained weight loss, or abdominal pain
- Prolapsed tissue becomes painful, changes colour, or won't go back in
- Your symptoms are significantly affecting your day-to-day life
Treatment options by grade
Grade I: Diet, lifestyle, and topical therapy
The main treatment is improving stool consistency — aiming for 25–35g of dietary fibre per day, drinking plenty of water, and not spending too long sitting on the toilet. Topical creams can ease symptoms in the meantime. If bleeding persists despite 6–8 weeks of dietary changes, rubber band ligation (banding) can be done as a simple in-rooms procedure for Grade I haemorrhoids.
Grade II: Rubber band ligation (banding)
Banding is the go-to treatment for Grade II haemorrhoids and it works very well. A small rubber band is placed around the base of the haemorrhoid, cutting off its blood supply. The tissue shrinks and falls away within 7–10 days. One or two sessions is usually enough for lasting relief. It's done in the clinic without anaesthetic, takes about 10 minutes, and most people go straight back to normal activity the same day.
Grade III: Banding or surgery
Grade III haemorrhoids can sometimes be managed with banding — particularly if they're not very bulky and the prolapse only happens occasionally. Multiple sessions may be needed. For larger or more persistent Grade III haemorrhoids, surgical haemorrhoidectomy is more reliably effective and has a lower chance of coming back. The right choice depends on the size of your haemorrhoids, how much prolapse is happening, your preferences, and your overall health.
Grade IV: Surgery
Permanently prolapsed haemorrhoids need surgery. Haemorrhoidectomy (surgical removal under general anaesthetic) is the gold standard. The recovery is real — most people have significant pain for the first 5–10 days, can return to desk work around 2 weeks, and reach full recovery by 4–6 weeks — but the long-term results are excellent, with recurrence rates well under 10% at five years.
If a Grade IV haemorrhoid is acutely strangulated or thrombosed (very painful and swollen), urgent surgical assessment is needed. Depending on what's happening, the surgeon may recommend a small bedside incision, semi-elective surgery within a few days, or simply observation with pain relief if the acute phase has already passed.
When surgery is needed
Surgery is needed when haemorrhoids are Grade IV, when Grade III haemorrhoids haven't responded to non-surgical treatment, or when there are large external haemorrhoids causing significant symptoms that banding can't address. But grade alone isn't the whole story — what really matters is how much your symptoms are affecting your life. Some people with Grade III haemorrhoids manage comfortably with conservative measures; others find Grade II symptoms genuinely intolerable. This is a conversation to have with your surgeon, not a decision made by a number alone.
Frequently asked questions
To a reasonable degree, yes. If you have bleeding but nothing ever protrudes, Grade I or II is likely. If you've noticed tissue that comes out but goes back in on its own, Grade II is probable. If you have to push tissue back in with your finger, that's Grade III. If something is always present outside and won't go back in at all, that sounds like Grade IV. But accurate grading needs a proper clinical assessment — a specialist will use a small scope (proctoscope) to examine things properly.
Yes, they can. Without treatment and without addressing the underlying causes, Grade III haemorrhoids tend to progress over time. Keeping your stools soft and avoiding straining can slow this down, but Grade III haemorrhoids usually need some kind of intervention to prevent things from worsening.
If your symptoms are mild, well controlled with dietary changes, and you're under 40 with no worrying features, GP management is completely appropriate. If symptoms are persistent, getting worse, or involve significant prolapse — or if you're over 40 with new rectal bleeding — it's worth asking for a referral to a colorectal surgeon.
Yes — successful treatment can resolve the grade entirely. After banding, a Grade II haemorrhoid may disappear completely. After haemorrhoidectomy, there's nothing left to grade. Think of the grade as a snapshot of where things are right now, not a permanent label.
Haemorrhoids are usually diagnosed on clinical examination and a proctoscopy (a quick look with a small scope), not a full colonoscopy. That said, colonoscopy is recommended if you're over 40 with rectal bleeding, if there's any change in your bowel habits alongside the bleeding, or if you have a family history of bowel cancer — to make sure nothing more serious is being missed.
Not sure what grade you're dealing with?
The only way to know for sure is a proper examination. If your haemorrhoids are causing you trouble, ask your GP for a referral to Mr Ba Nguyen — or contact our rooms directly on (03) 9816 3951. Send an enquiry →