Piles Info
Internal piles are graded by prolapse: whether they stay inside, come out and go back, need manual reduction, or remain outside. Grade helps decide the safest treatment.
Quick Grade Guide
The more prolapse, the higher the grade.
Used for
Internal piles
Based on
Prolapse severity
Treatment changes by
Grade + symptoms
Internal Piles Grades
The grading system describes internal piles by how much they prolapse. It does not fully describe external piles, thrombosed piles, pain severity or bleeding risk, so examination is still important.
Important: Grade is only one part of the decision. Bleeding, pain, thrombosis, anaemia, pregnancy, medicines and overall health also affect treatment choice.
Grade 1
Internal piles are enlarged but stay inside the anal canal. Bleeding may occur, but tissue does not come out during stool.
Common treatment direction
Fibre, fluids, stool correction, medicines and follow-up. Office treatment may be considered if bleeding persists.
Grade 2
Piles come out during straining or stool but reduce spontaneously after bowel movement.
Common treatment direction
Lifestyle correction, medicines, rubber band ligation, infrared coagulation or laser options in selected cases.
Grade 3
Piles come out during stool and need to be pushed back manually. Symptoms are usually more frequent.
Common treatment direction
Often needs procedural treatment such as laser haemorrhoidoplasty, MIPH, banding in selected cases or surgery.
Grade 4
Piles remain outside and cannot be reduced. They may become painful, swollen, ulcerated or trapped.
Common treatment direction
Usually requires specialist treatment. Surgery, laser-assisted care or haemorrhoidectomy may be needed.
Comparison
Grade is assigned during examination, usually with anoscopy or proctoscopy. A symptom description alone is useful, but it is not enough for accurate grading.
Read Diagnosis GuideHistory of bleeding, pain, constipation, prolapse and manual reduction.
Visual inspection for external swelling, prolapse or thrombosis.
Digital rectal examination where appropriate.
Anoscopy or proctoscopy to see internal piles and assign grade.
Colonoscopy if bleeding pattern, age or risk factors require bowel evaluation.
Treatment decision based on grade, symptoms, health status and patient preference.
FAQ
Grade 3 and Grade 4 piles are more advanced because prolapse is recurrent or remains outside. Grade 4 piles, severe pain, trapped tissue or heavy bleeding need prompt specialist review.
They can progress over time if constipation, straining and pressure continue, but progression is not automatic. Early bowel correction and treatment reduce risk.
Some Grade 2 piles improve with fibre, hydration, stool softening and medicines. Recurrent bleeding or prolapse may need office procedures or laser treatment.
Grade 3 piles often need procedural treatment because they prolapse and require manual reduction. The exact option depends on anatomy, symptoms and examination.
The Grade 1 to Grade 4 system is mainly used for internal piles based on prolapse. External piles are described by swelling, pain, thrombosis and skin changes.
RectoRelief Hospital
Our team grades internal piles, checks for external disease or thrombosis, and recommends the safest treatment plan.
Medical references used for this guide
Content reviewed against patient education from ASCRS, Mayo Clinic, and Cleveland Clinic. This page is educational and does not replace a clinician's examination.