How are internal hemorrhoids graded?

Updated: Feb 03, 2022
  • Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Most clinicians use the grading system proposed by Banov et al in 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches, as follows.

  • Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse

  • Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases (ie, return to their resting point by themselves)

  • Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction (ie, require manual effort for replacement into the anal canal)

  • Grade IV hemorrhoids chronically prolapse and cannot be reduced; these lesions usually contain both internal and external components and may present with acute thrombosis or strangulation

Similarly and more simply, the 2018 American Society of Colon and Rectal Surgeons (ASCRS) guidelines for the management of hemorrhoids classify internal hemorrhoids into the following four grades [14] :

  • Grade I: Prominent hemorrhoidal vessels, no prolapse

  • Grade II: Prolapsed hemorrhoids with Valsalva maneuver; spontaneously reduces

  • Grade III: Prolapsed hemorrhoids with Valsalva maneuver; manual reduction is required

  • Grade IV: Chronically prolapsed hemorrhoids; manual reduction is ineffective

However, the classification of hemorrhoids continues to evolve, with potential future elements to include prolapse, bleeding, and pain, and may involve considerations of comorbidities and female sex. [15] One new classification proposes taking into account the following three factors [15, 16] :

  • The evolutionary nature of hemorrhoidal disease (to overcome the internal/external hemorrhoids division; consider prolapse)

  • The prevalent symptomatology regardless of prolapse grade

  • The etiopathogenetic and (female) sex aspect

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