Grade 1, 2, 3 and 4 Hemorrhoids – Differences and Treatment of Each

Content author: MD. Sara Godyńska, proctologist · Editorial work: Editorial team of Wyspa Medycyny Przyjaznej · Medical review: lek. Sara Godyńska · Date of creation: 07.08.2026 · Date of review: 07.08.2026 · Updated: 07.08.2026

The article is of an educational nature and does not replace a proctological examination. Heavy bleeding, black, tarry stool, weakness, fainting, fever with severe pain around the anus, and a sudden, very painful lump that cannot be drained require urgent medical attention. Rectal bleeding always requires determining the cause - regardless of the degree of hemorrhoidal disease.

The most important information at a glance

• Grades 1–4 only describe the loss of hemorrhoids, not the severity of the symptoms.
• Grade 1: nodules do not fall out; the dominant symptom is painless bleeding.
• Grade 2: The lumps fall out on pushing and regress on their own.
• Grade 3: nodules fall out and require removal by hand.
• Grade 4: nodules remain external and cannot be drained.
• The basis of treatment at every stage is the regulation of bowel movements - without it, each method works for a shorter time.
• In stages 1-2, and in some patients also 3, outpatient procedures are used, such as rubber banding or laser methods.
• Stage 4 usually requires surgical treatment, although the decision is always individual.
• The degree does not always increase over time - in some patients symptoms stabilize for many years.
• A blood clot in a hemorrhoid is a separate situation that does not have a grade.

Find out more about the specialist

Doctor. Sara Godyńska is a proctologist at Wyspa Medycyny Przyjaznej in Gdańsk. He deals with the diagnosis and treatment of diseases of the anal area, including hemorrhoidal disease. In this diagnosis, it is crucial to combine two pieces of information: the degree of advancement visible in the examination and what is really bothering the patient - because only together do they determine a sensible treatment plan.

Meet the doctor. Sara Godyńska

What do the grades actually describe?

Hemorrhoids are a normal anatomical structure - vascular plexuses in the anal canal that every person has and which participate in the mechanism of stool and gas continence. We only talk about hemorrhoidal disease when they enlarge and the structures supporting them weaken.

A commonly used classification divides the disease into four stages based on one criterion: whether the nodules fall outside the anal canal and whether they return on their own. That's all. The classification does not take into account the amount of bleeding, pain or itching.

This is the most common misunderstanding. The patient hears "first degree" and perceives it as a "trivial problem", although he may bleed profusely and have anemia. Another hears "third degree" and expects surgery, although his symptoms are moderate and outpatient treatment is sufficient.

That's why we always compare two things in the office: the degree visible in the examination and what actually interferes with the patient's everyday life. We treat the symptoms and their cause, not just the number in the description.

Grades 1-4 in the table

It is worth adding one anatomical note that explains the course of symptoms. Internal hemorrhoids are located in the part of the anal canal that has poor sensory innervation - that's why they usually don't hurt. The pain appears only when they go lower, when an external lesion joins, when there is a clot or when there is an anal fissure.

Grade 1 - bleeding without pain

The nodules are enlarged but remain in the anal canal. The patient usually does not feel or see anything. The most common, and often the only, symptom is bright red blood: on the paper, on the surface of the stool, or dripping into the toilet bowl after a bowel movement. No pain.

Treatment is based primarily on conservative treatment: regulating bowel movements, a diet rich in fiber, adequate hydration, giving up pushing and shortening visits to the toilet. Topical preparations may relieve symptoms. In patients with persistent bleeding despite these changes, outpatient procedures are considered.

A note that applies to this degree the most: no pain does not mean no problem. Chronic, even minor bleeding over time leads to iron deficiency anemia - with weakness and shortness of breath on exertion, which the patient does not associate with hemorrhoids. And it is in the case of grade 1 that bleeding of a completely different cause is most often attributed to hemorrhoids.

Grade 2 - prolapse that goes away on its own

When pushing, the lumps protrude beyond the anal canal and return spontaneously after the bowel movement. So the patient begins to sense something - usually describing it as "something coming out and hiding itself." The bleeding is accompanied by a feeling of incomplete evacuation and wetness.

This is the stage in which outpatient procedures work best. Methods such as rubber banding or laser treatments allow you to reduce the nodules and restore their proper fixation, without the need for surgical treatment. They are performed in the office, usually in several sessions, and the patient returns to normal activity on the same day or limits it only for a short time.

A detailed description of available methods - including rubber banding and laser treatment - can be found on the treatment page: treatment of haemorrhoids and hemorrhoids.

Grade 3 - Must be drained by hand

The lumps fall out with a bowel movement, and sometimes also with exertion, coughing or standing for a long time - and they do not come back on their own. The patient must remove them with his finger. This is the moment when the disease begins to significantly affect everyday functioning.

Symptoms include dampness of the area and soiling of underwear - falling lumps disturb the tightness of the anus, causing mucus to leak out. The consequence is skin irritation and persistent itching, which for many patients is more troublesome than the bleeding itself.

The procedure here is the most individualized. Outpatient procedures are still effective in some patients, especially when the lesions are not very advanced and concern single nodules. In others - with extensive lesions, a large external component or ineffectiveness of previous treatment - surgical treatment is considered. The decision depends on the image in the examination, the severity of symptoms, comorbidities and the patient's expectations.

Grade 4 - nodules remain out

Nodules are permanently prolapsed and cannot be removed. The discomfort is constant and not solely related to bowel movements. Persistent humidity leads to irritation and maceration of the skin, itching, staining of underwear and the feeling of a foreign body are common.

At this stage, conservative treatment and outpatient procedures are usually not enough - they may alleviate symptoms, but will not restore normal anatomy. The standard procedure is surgical treatment, the scope and technique of which are selected individually. The final decision always takes into account the patient's health condition, comorbidities and medications taken.

There is one situation at this stage that requires urgent help: entrapment of prolapsed lumps. This causes swelling and tightening, the pain increases rapidly, and the blood supply to the tissues is impaired. It is manifested by sudden, very severe pain and a hard tumor that cannot be removed. This is not a situation where you can make an appointment in a week.

Treatment tailored to the stage

Regardless of the degree, there is one rule that is easy to forget when talking about treatments: without regulating bowel movements, each method works for a shorter time. Constipation, pushing and sitting on the toilet for a long time are the mechanism that led to the disease - and which will lead to it again after the procedure if it is not changed.

It is also worth knowing that outpatient procedures concern the internal component. If external changes or skin folds coexist, they require separate treatment - and it is worth talking about this before the procedure so that expectations match what a given method can change.

Does the disease always progress?

No. This is a common concern for patients who hear about a four-step scale and assume that going through all the stages is inevitable. This is not the case. For many people, symptoms remain stable for years, especially if they manage to permanently change their bowel habits.

Progression is accelerated by specific factors: chronic constipation, tenesmus, prolonged sitting and sitting on the toilet, low-residue diet, insufficient hydration, obesity, pregnancy and childbirth, lifting, and strength training with breath holding under heavy loads.

It also works the other way around: registering early means more options available. In stages 1–2, the least burdensome methods performed in the office are usually sufficient. The higher the level, the more the range of possible solutions narrows.

What grades don't cover

The classification concerns internal hemorrhoids and their prolapse. Apart from this, there are several situations that are sometimes confused with them:

• Blood clot in a hemorrhoid - a sudden, hard, blue and very painful lump at the edge of the anus. It is not described by degrees and requires separate treatment, and different treatment options are available in the first days than later.
• Skin folds - soft, painless remnants of a blood clot or swelling. They are not hemorrhoids and do not require treatment for medical reasons.
• Anal fissure - sharp, cutting pain during and after defecation with minor bleeding. A completely different diagnosis and treatment.
• Abscess and fistula - throbbing pain, fever, discharge of pus. They require urgent intervention.
• Diseases of the large intestine — polyps, inflammatory diseases, cancer. They may cause bleeding and may coexist with hemorrhoids.

The last point deserves emphasis. Most adults have hemorrhoids, so they can almost always be diagnosed in a patient with bleeding, regardless of whether they are responsible for the symptoms. Therefore, the diagnosis of the stage does not end the diagnosis if there are alarm symptoms: blood mixed with stools, change in bowel habits, weight loss, anemia, first bleeding after the age of 45-50. years of age or a family history of colon cancer.

What helps at every stage

The goal is always the same: bowel movements should be soft, regular and quick. It has a preventive effect, supports conservative treatment and reduces the risk of recurrence after surgery.

• fiber in the diet: vegetables, fruits, whole grains, legumes,
• adequate amount of fluids during the day,
• responding to the need to defecate instead of postponing it,
• short visits to the toilet - without a phone and without sitting,
• giving up pushing; in case of difficulties, it is better to soften the stool than to struggle,
• a footrest for the feet, changing the angle of bending and facilitating defecation,
• regular physical activity and breaks from long periods of sitting,
• during strength training, proper breathing, without holding the air,
• gentle hygiene - washing with lukewarm water instead of rough water paper,
• sitz baths in lukewarm water for severe symptoms.

Most common myths

• "Grade 1 is nothing serious." Not always. At this level, bleeding can be profuse and leads to anemia.
• "Grade 3 means surgery." Not always. Outpatient procedures are effective for some patients.
• "The disease always goes through all stages." No. In many people, symptoms stabilize for years.
• "If it doesn't hurt, it's not hemorrhoids." Conversely, internal hemorrhoids usually do not hurt.
• "After the procedure, the problem disappears forever." No. Without changing habits, the symptoms may return.
• "The treatment will also remove skin folds." Not always. Outpatient procedures involve an internal component.
• "The bleeding is definitely from hemorrhoids." No. Hemorrhoids may coexist with another intestinal disease.
• "The ointment will cure any degree." No. Topical preparations alleviate the symptoms, but do not reverse the loss of nodules.

Don't know what stage your hemorrhoidal disease is at?

The degree is assessed in a proctological examination. It depends on it and the severity of symptoms whether conservative treatment, outpatient surgery or surgery is enough.

Hemorrhoids treatment at the Friendly Medicine Island in Gdańsk

In the Island of Friendly Medicine, Dr. Sara Godyńska consults patients with hemorrhoidal disease and other ailments of the anal area. The visit includes an interview, proctological examination, staging and discussion of treatment methods appropriate to the clinical picture and severity of symptoms.

Part of a reliable qualification is also an indication of when the procedure is not yet needed and conservative treatment is sufficient, and when further diagnosis of the large intestine is necessary. The current scope of treatments, availability of dates, prices and rules of preparation for the visit should be confirmed during registration.

Find out more about the medicine. Sara Godyńska Treatment of hemorrhoids

What to ask a proctologist?

• What degree of hemorrhoidal disease have I been diagnosed with?
• Do my symptoms match this grade?
• Is conservative treatment enough in my case?
• Which treatment methods are available and why these?
• How many sessions will be needed and what does the period after the procedure look like?
• Will the treatment also cover external changes and skin folds?
• What is the risk of recurrence and what reduces it?
• Do I need colon diagnostics?
• Should I or should I have a blood test done for anemia?
• How to regulate bowel movements to make the treatment last longer?
• Do the medications I take influence the choice of method?
• What symptoms mean that I need to come in urgently?

FAQ - Hemorrhoid grades

What do grades 1-4 mean?

They describe whether hemorrhoids fall outside the anal canal and whether they come back on their own. Grade 1 - do not fall out, 2 - fall out and retract spontaneously, 3 - require removal by hand, 4 - remain outside.

Does the grade correspond to the severity of symptoms?

No. The classification only applies to prolapsed nodules. A patient with grade 1 may bleed profusely, and a patient with grade 3 may have no pain. Therefore, treatment is selected according to the degree and symptoms combined.

Who assesses the grade?

Doctor during a proctological examination, including examination of the area, finger examination and, if indicated, anoscopy. It is impossible to determine the degree alone or based on symptoms alone.

Does grade 1 require treatment?

The basis is conservative treatment and regulation of bowel movements. If bleeding persists despite these changes, outpatient procedures are considered. The bleeding itself always requires determining the cause.

Does grade 3 always mean surgery?

No. For some patients, outpatient procedures remain effective, especially when the lesions are not extensive. The decision depends on the examination findings, symptoms, comorbidities and patient expectations.

What is rubber banding?

This is an outpatient procedure used mainly in stages 1–3, which involves placing a rubber ligature on the base of the lump. Details of the method, course and recommendations are described on the procedure website.

Do hemorrhoids hurt?

Internal hemorrhoids usually do not hurt because they are located in the part of the anal canal with poor sensory innervation. Pain occurs with external lesions, thrombus, incarceration or concomitant anal fissure.

Does the disease always progress?

No. For many patients, symptoms remain stable for years, especially after permanent changes in habits. Progression is accelerated by constipation, pushing, sitting for long periods of time, obesity, pregnancy and lifting.

Can hemorrhoids come back after the procedure?

Yes, especially if the factors that led to the disease persist. Therefore, regulating bowel movements is an element of treatment, not an addition to it.

What is the difference between a blood clot and a high grade?

A blood clot is a sudden, hard, blue and very painful lump at the edge of the anus that develops within hours. It is not described by degrees and requires separate treatment, and early reporting provides more treatment options.

When should I report urgently?

In case of heavy bleeding, black tarry stool, weakness and fainting, fever with severe pain around the anus and a sudden, very painful lump that cannot be removed.

Who treats hemorrhoids at WMP?

On the WMP website, MD. Sara Godyńska is described as a proctologist dealing with the diagnosis and treatment of diseases of the anal area. The scope of treatments and availability of dates are confirmed by registration.

Sources

• Island of Friendly Medicine, MD. Sara Godyńska: https://www.wyspamedycynyPrzyjaznej.pl/pl/sara-godynska-proktolog
• Wyspa Medycyny Przyjaznej, treatment of hemorrhoids and hemorrhoids: https://www.wyspamedycynyPrzyjaznej.pl/pl/leczenie-zylakow-odbytu-hemoroidow-gdansk
• NHS, Piles (haemorrhoids): https://www.nhs.uk/conditions/piles-haemorrhoids/
• NHS, Rectal bleeding (bleeding from the bottom): https://www.nhs.uk/symptoms/rectal-bleeding/
• NHS, Anal fissure: https://www.nhs.uk/conditions/anal-fissure/
• NHS, Constipation: https://www.nhs.uk/conditions/constipation/
• NHS, Iron deficiency anemia: https://www.nhs.uk/conditions/iron-deficiency-anaemia/
• NICE Clinical Knowledge Summaries, Haemorrhoids: https://cks.nice.org.uk/topics/haemorrhoids/
• NICE, Suspected cancer: recognition and referral (NG12): https://www.nice.org.uk/guidance/ng12
• American Society of Colon and Rectal Surgeons, Clinical Practice Guidelines: https://fascrs.org/healthcare-providers/education/clinical-practice-guidelines