Inflamed hemorrhoids can cause itching, bleeding, and pain that does not go away quickly. If going to the bathroom has become a dreaded task, you need immediate medical attention. Hemorrhoids may become a severe annoyance that affects your quality of life, but there is no need to panic. There are effective treatment options that provide quick relief and help you enjoy life without any discomfort. Knowing about the hemorrhoid grading systems and their symptoms can help you reach out to experts for care and treatment. Hemorrhoids may clear up on their own but not always. Visit Gastroenterology practice in New York to consult top-rated gastroenterologists regarding your painful symptoms and the severity of hemorrhoids. Hemorrhoid and gastrointestinal specialists not only recommend the best treatment options but also resolve the issues that led to the problem in the first place to provide lasting relief.

Hemorrhoids are a regular part of your everyday anatomy. They are clusters of venous structures in the rectal area. They acts like vascular cushions, protect the anal sphincter and aid closure of the anal canal during increased abdominal pressure. They offer sensory information that helps differentiate between stool, liquid, and gas.

The existence of hemorrhoids is not the issue. The problem develops when these veins become swollen and inflamed due to some reason. When they become irritated and inflamed, it can lead to symptoms ranging from annoying to downright miserable, depending on their severity. Known causes of hemorrhoids include pregnancy, chronic constipation, diarrhea or prolonged straining, weight lifting, and weakening of supporting tissue due to aging or genetics.

The Grading System for Hemorrhoids

Hemorrhoid Grading System
Hemorrhoid Grading System

Hemorrhoids are graded or classified according to their position relative to the dentate line, a line that divides the upper two-thirds and lower third of the anal canal. External hemorrhoids lie below the dentate line, are covered by squamous epithelium, and innervated by cutaneous nerves.

Internal hemorrhoids arise above the dentate line. They are covered by columnar cells and have a visceral nerve supply. They are identified and treated according to their degree of prolapse. Internal hemorrhoid symptoms include bright red bleeding with bowel movements, a sense of pressure, discomfort or incomplete emptying of bowels, and rectal leakage.

Doctors usually 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 correlates with symptoms and helps determine the best therapeutic approach for quick relief.

Grade 1

Grade 1 hemorrhoid protrudes into the anal canal but does not slip or move outside the anus. These are internal hemorrhoids that stay inside. To eliminate these hemorrhoids, doctors usually recommend increasing fiber intake and one of the many new over-the-counter hemorrhoid treatments.

Some popular over-the-counter hemorrhoids treatments include:

  • Preparation H
  • Proctofoam
  • Tucks hydrocortisone ointment
  • Analpram hydrocortisone cream

These creams and ointments reduce inflammation, irritation, swelling, and itching from hemorrhoids.

Grade 2

Grade 2 hemorrhoid protrudes through the anus during straining or as the stool passes, but it spontaneously returns to its previous position. It is an internal hemorrhoid that comes out but goes back to the anus without needing assistance.

To treat grade 2 hemorrhoids, doctors usually begin with conservative therapies that include medications and procedures used for grade 1 hemorrhoids and move on to other treatment procedures as needed. These are painless in-office hemorrhoid procedures that help to get rid of these discomforting occurrences without any complications.

Treatment therapies for grade 2 hemorrhoids include:

  • Rubber band ligation – During the procedure, the doctor inserts a small tool called a litigator through a scope into the anal canal and grasps hemorrhoid with forceps. The rubber band is released around the base of the hemorrhoid. The rubber band cuts off the hemorrhoid’s blood supply, causing it to wither and drop off.
  • Injection sclerotherapy – A chemical solution is injected into the area around the hemorrhoid, which causes a scarring reaction. As a result, hemorrhoids gradually shrink or fade over time.
  • Infrared coagulation – It is a non-surgical outpatient procedure for the treatment of hemorrhoids. It involves using infrared light as a heat source to quickly coagulate or clot the vessels supplying blood to the hemorrhoids.

The best thing about these procedures is that they can be performed without anesthesia at the clinic and cause minimal discomfort. However, it is essential to note that all these treatments are performed on internal prolapsed hemorrhoids only. They do not work for external hemorrhoids. Also, they can require multiple applications before you get desired relief. Remember that these procedures do not address the source of the problem. Thus, they are not curative. They can last six months to a year before they need to be repeated.

To get rid of the grade 2 hemorrhoids, you must consult your healthcare provider, who will advise lifestyle and dietary changes to help you achieve lasting relief.

Grade 3

Grade 3 hemorrhoids protrude through the anus during straining or passing the stool, but they must be returned to their position. They remain prolapsed outside of the anus unless you put them back.

Although grade 3 is not the most severe type of hemorrhoid, it indicates a serious problem that requires immediate attention. The doctor may even recommend you undergo surgery to correct the problem.

Symptoms of grade 3 hemorrhoid include:

  • Bleeding on the toilet paper when you wipe after a bowel movement or blood in the toilet bowl
  • Discomfort
  • Pain
  • Itching
  • Irritation in the rectal area
  • Swelling and inflammation in the region

Grade 3 hemorrhoids extend out the rectum during the bowel movement and can be pushed back into place with your hand, but they do not go back on their own. Grade 3 should be treated before they turn into grade 4 and even more painful and irritating.

These hemorrhoids may get worse over time and move from a lesser grade to a higher one if they are not treated timely and you do not follow the doctor’s advice regarding your diet and habits.

Treatment options for grade 3 hemorrhoids are usually surgical. The advanced technology ensures that minimally invasive surgical treatments effectively take care of these serious hemorrhoids. Treatments include:

  • Hemorrhoid banding – It is also known as rubber band litigation. Even though it is usually reserved for grade 1 and 2 hemorrhoids, some grade 3 hemorrhoids can also be treated with this procedure. A small rubber band is slipped over the hemorrhoid to restrict blood flow to the tissue. Due to lack of blood, the hemorrhoids withers and falls off.
  • Laser removal – Laser procedure works well for grade 3 hemorrhoids. A small laser fiber is inserted directly into the hemorrhoid. The light energy from the laser works to close off the blood supply to the tissue. This coagulation shrinks hemorrhoid, and it disappears after a short time.

Both these processes are relatively painless, take very little time, and you can return to normal life activities within a few days.

Grade 4 Hemorrhoid

Grade 4 hemorrhoids remain prolapsed outside of the anus. They are internal hemorrhoids that protrude but do not go back inside the anus until you push them back in. Grade 4 hemorrhoids are the most severe level of internal hemorrhoids, and you will notice painful symptoms as these vessels enlarge.

Acutely thrombosed hemorrhoids and those involving rectal mucosal prolapse are also classified as grade 4. Commonly experienced symptoms of grade 4 hemorrhoids include:

  • Rectal bleeding
  • Mucus discharge
  • Pain and discomfort
  • rning sensation
  • Feelings of itching, stinging, or soreness
  • Hemorrhoid production from the anus

Grade 4 hemorrhoids are permanently prolapsed and affect your life, making walking, sitting, and standing difficult for you.

Grade 4 hemorrhoids can only be treated with invasive treatment procedures. They include:

  • Hemorrhoidectomy – Excisional hemorrhoidectomy or surgical hemorrhoid excision is the most effective treatment that offers the best results. However, it is painful, and the recovery takes time.
  • Stapled hemorrhoidectomy – It is a far less painful procedure because of the incision location. A unique device cuts a rim of the tissue in a circular shape inside the anus where they are no nerve endings. At the same time, the instrument uses small staples to hold the tissue together. Removing a rim of tissue disrupts the blood supply to the hemorrhoids, and the hemorrhoids are lifted back in place.

For any of the procedures, doctors recommend gently treating your healing rectum by using stool softeners or eating a bowel-friendly diet during recovery.

Even though you cannot see hemorrhoids, you can feel the pain and discomfort. The inflammation begins inside the rectum and worsens over time. As it develops, it results in symptoms that take more time to heal if you do not seek timely medical help.

Call Manhattan Gastroenterology to schedule an appointment with experienced and board-certified gastroenterologists to learn more about hemorrhoids, which type you suffer from, and how they can be treated. Knowing about the hemorrhoid grading system can help you understand your problem, find the best healing for your condition, and prevent them from recurring and causing further pain. The top hemorrhoid specialists recommend the best treatment options that are minimally invasive and get you back to routine life without too much recovery time.

Updated on Sep 1, 2023 by Dr. Shawn Khodadadian (Gastroenterologist) of Manhattan Gastroenterology