How Are Hemorrhoids Graded?

Medically reviewed by: Gary H. Hoffman, MD

Hemorrhoids are more common than most people realize. One study found that approximately 10 million people in the United States are suffering from hemorrhoids at any given time.  Since most people are hesitant to talk to their doctors about their symptoms and first try over-the-counter treatments, the actual numbers could be much higher.

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Why Is It Important To See A Doctor About My Symptoms?

While many avoid awkward conversations with their healthcare provider, it is a good idea to talk to your doctor if your symptoms persist for more than a week. The symptoms people assume are hemorrhoids can also indicate a number of other, more serious conditions.

While most people assume any rectal bleeding is due to hemorrhoids, it could be another minor condition, such as an anal fissure, or as serious as colon or rectal cancer. The only way to be sure is through a visual examination from an experienced proctologist. In fact, studies have found that even doctors struggle to make the correct diagnosis based on symptoms alone. Some reports show that as many as half of all patients who were initially diagnosed as having hemorrhoids based on their symptoms were later given a different diagnosis after a more thorough examination.

How Severe Are My Hemorrhoids?

Your doctor will ask questions about your symptoms and then examine you visually. A manual exam may also be used to determine the location and severity of your hemorrhoids. They may be classified as internal, external or mixed. Internal hemorrhoids are often painless but may become painful, bleed, and lead to accidental soiling if they prolapse. External hemorrhoids are often asymptomatic.

As a part of the diagnosis, internal hemorrhoids will also be staged, also known as grading. The grades range from grade I to grade IV. Grade I is the least severe, increasing in severity to grade IV.   Grade I hemorrhoids have no prolapse and are usually painless. Bleeding may be the only symptom. Grade II are more uncomfortable, and they prolapse, but the prolapse resolves on its own quickly. Grade III is more severe, with a prolapse that will not resolve on its own but can be manually pushed back inside. Grade IV hemorrhoids have prolapsed and cannot be replaced manually. They may be the most painful and may include a variety of other symptoms.

How Are Grades I and II Treated?

Most people, between 80 and 99 percent, can find relief through noninvasive methods.  Doctors typically begin treatment for all hemorrhoids with diet and lifestyle changes, as well as over-the-counter medications. This is especially true of grades I and II.

Straining to use the bathroom is a common cause of hemorrhoids, so curing constipation is a common first-line treatment. Your doctor may recommend a diet high in fiber, along with drinking plenty of water. In some cases, a stool softener or laxative may be prescribed and should be used according to your doctor’s instructions.

Other factors may include obesity, lack of exercise, and prolonged sitting, so your doctor may advise you to lose weight, remain active, and minimize the time you spend sitting. This is especially true of time spent on the toilet when your rectum is not properly supported.

For most people, these changes will provide relief within two weeks, if not sooner. Nonresponsive grade II or grade III hemorrhoids, however, may require a more invasive treatment. Painless hemorrhoid injections, also referred to as sclerotherapy, are highly effective in addressing minor itching or bleeding associated with hemorrhoids.  Rubber band ligation is often used to cut off the blood supply to these hemorrhoids, allowing the tissue to fall off on its own. Studies show this is a very effective treatment, with a long-term success rate of about 80 percent.

How Are More Severe Hemorrhoids Treated?

When grade III and IV hemorrhoids do not respond to less invasive treatments, surgery may be necessary. A hemorrhoidectomy may also be used to treat external hemorrhoids or mixed hemorrhoids, where they occur both internally and externally. Some cases may instead call for stapled hemorrhoidopexy (PPH) or transanal hemorrhoidal dearterialization (THD).

While PPH and THD have become popular for treating severe hemorrhoids, a traditional hemorrhoidectomy procedure continues to be used in selected cases by many doctors. It is an effective method of treating hemorrhoids and reducing the risk of recurrence. This procedure involves surgical removal of the hemorrhoid. While it is usually done as a day surgery, the recovery can be painful and may require a week or more of missed work.

The most important factor in selecting the best procedure for you is the experience of your surgeon.  Your doctor will be able to explain the pros and cons of all procedures, based on the specifics of your condition.

Los Angeles Colon and Rectal Surgical Associates

The board-certified surgeons of Los Angeles Colon and Rectal Surgical Associates are experts on hemorrhoid diagnosis and treatment. They are specialists in all diseases of the colon, rectum and anus. By calling (310) 273-2310, you can schedule a confidential appointment and discuss any of your questions with your physician.

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