Hemorrhoid Stages

What are the four stages of hemorrhoids, and how do they differ?

Hemorrhoids are classified into four stages (grades) depending on their severity, each with different symptoms and characteristics. This classification helps to understand the condition, correctly categorize the symptoms of hemorrhoids, and consequently take appropriate measures for the treatment of hemorrhoids:

Hemorrhoids Grade I: In this early stage, the hemorrhoids are enlarged but remain completely inside the anal canal and are not visible from the outside. Affected individuals usually notice no or only minor discomfort. Typical symptoms can include bright red blood traces after bowel movements, slight itching, or burning in the anal area. Often, Hemorrhoids Grade I are discovered incidentally during medical examinations.

Hemorrhoids Grade II: In Hemorrhoids Grade II, the vascular cushions are more enlarged and protrude from the anal canal during strain such as bowel movements or physical exertion. However, they retract on their own. Symptoms like itching, burning, moisture, and occasional bleeding are common. This stage is often accompanied by a foreign body sensation or slight pressure in the anal area.

Hemorrhoids Grade III: In this advanced stage, the hemorrhoids are so enlarged that they protrude outward during strain (e.g., bowel movement) and no longer retract on their own. They must be manually pushed back into the anal canal. Those affected by Grade III hemorrhoids often suffer from more severe symptoms such as persistent moisture, bleeding, pain, and itching. This stage can significantly impact daily life.

Grade IV hemorrhoids: The most severe stage is characterized by permanently prolapsed hemorrhoids that can no longer be pushed back. They are visible from the outside and can cause severe symptoms such as pain, bleeding, inflammation, and mucosal prolapse (anal prolapse). Stage Grade IV hemorrhoids often requires intensive medical treatment to avoid complications.

How to recognize hemorrhoids in the early stage (Grade I)?

Hemorrhoids in the early stage (Grade I) are often difficult to detect because they usually cause no severe symptoms at this early stage and remain hidden in the anal canal. However, there are some typical signs that may indicate Grade 1 hemorrhoids.

Typical symptoms of Grade I hemorrhoids

Mild bleeding: Small amounts of bright red blood often appear on the toilet paper or in the stool. This occurs when hard stool injures the sensitive vascular cushions. Read more about bleeding hemorrhoids here.

Itching and burning: Occasionally, affected individuals report mild itching or burning in the anal area. This is often due to irritation of the mucous membrane.

Feeling of incomplete emptying: There may be a subjective feeling that the bowel is not completely emptied after using the toilet.

No visible changes: From the outside, Grade I hemorrhoids are not visible because the enlarged vascular cushions remain entirely inside the anal canal.

Which signs indicate Grade II hemorrhoids?

Grade II hemorrhoids are characterized by clear symptoms that often occur during or after bowel movements. In this stage, the enlarged vascular cushions temporarily protrude from the anal canal but retract on their own. Typical signs include.

Characteristic symptoms of Grade II hemorrhoids

Temporary protrusion of hemorrhoids: The hemorrhoids protrude from the anal canal when straining, for example during bowel movements, but retract on their own after emptying.

Bleeding: Bright red bleeding, visible on toilet paper or in the stool, occurs more frequently. This is caused by the friction of the stool against the sensitive vascular cushions. Read more here about bleeding hemorrhoids.

Itching and burning: The mucous membrane of the temporarily protruding hemorrhoids can be irritated, leading to anal itching or anal burning.

Moisture and mucus discharge: Moisture in the anal area or mucus discharge may occur, which can further irritate the skin and make anal hygiene more difficult.

Foreign body sensation: Many affected individuals report a feeling of pressure or a foreign body sensation in the anus, especially after bowel movements.

Characteristics of Grade II Hemorrhoids

The temporary protrusion of hemorrhoids is a clear distinguishing feature from Grade I. Unlike Grade III, however, the hemorrhoids in this stage still retract on their own.

When should a doctor be consulted?

If symptoms persist or worsen despite hygienic and dietary measures, a doctor should be consulted. Especially with repeated bleeding or severe impairment of well-being, medical evaluation is important to rule out other causes such as anal fissures or polyps.

What happens with Grade III hemorrhoids, and why are they manually pushed back?

Grade III hemorrhoids represent an advanced stage of hemorrhoidal disease, where the vascular cushions are so enlarged that they permanently protrude from the anal canal during bowel movements or physical exertion. Unlike Grade II hemorrhoids, hemorrhoids at this stage no longer retract on their own but must be manually pushed back.

Typical features of Grade III hemorrhoids

Permanent protrusion: The hemorrhoids not only protrude during strong straining but can also become visible during everyday activities such as walking, sitting, or lifting loads.

Manual pushing back required: Since the natural return into the anal canal no longer occurs, those affected must carefully push the prolapsed vascular cushions back with their fingers to relieve pressure and discomfort.

Pain and itching: Friction and constant contact with clothing can cause pain, irritation, and an unpleasant itching sensation.

Bleeding: Frequent bright red bleeding occurs because the mucous membrane of the hemorrhoids is sensitive and easily injured. Read more about hemorrhoid bleeding here.

Moisture and mucus discharge: Moisture or mucus discharge in the anal area can lead to skin irritation and make hygiene more difficult.

Pressure and foreign body sensation: Affected individuals often feel a constant pressure sensation, perceived as a foreign body in the anal area.

Why do grade III hemorrhoids need to be manually pushed back?

Manual repositioning of the hemorrhoids is necessary to relieve symptoms and avoid complications.

Relief of tissue: If the hemorrhoids remain outside, reduced blood flow can cause swelling or painful strangulation.

Prevention of tissue damage: Pushing them back prevents the sensitive mucosa of the hemorrhoids from being further injured by friction.

Relief of pressure sensation: By pushing the hemorrhoids back into the anal canal, the unpleasant feeling of pressure and foreign body sensation decreases.

When is an anal prolapse (grade IV) diagnosed in hemorrhoids?

An anal prolapse is diagnosed in grade IV hemorrhoids when the enlarged vascular cushions permanently protrude from the anal canal and cannot be pushed back either spontaneously or manually. This advanced stage of hemorrhoidal disease is characterized by a pronounced bulge in the anal area, which is also visible from the outside. Often, a part of the anal mucosa has also prolapsed.

Characteristics of an anal prolapse at grade IV

Permanent protrusion: The hemorrhoids remain permanently outside the anal canal and can no longer be pushed back with fingers.

Additional mucosal prolapse: In addition to hemorrhoids, often a part of the anal mucosa also prolapses outward, which worsens the condition.

Severe symptoms: Patients often complain of persistent pain, itching, oozing, and a strong feeling of pressure or a foreign body.

Bleeding: Repeated bleeding caused by friction and the sensitive mucosa is common. The blood is usually bright red and appears during bowel movements or physical exertion. Read more about bleeding hemorrhoids.

Risk of complications: In Grade IV, the risk of tissue inflammation, infections, and thrombosis (blood clots in the hemorrhoids) increases. Additionally, tissue damage up to necrosis (tissue death) can occur if blood supply is restricted.

Why is it called an anal prolapse?

The term "prolapse" means the protrusion of tissue from its normal anatomical position. In Grade IV hemorrhoids, anal prolapse refers to the irreversible bulging of the hemorrhoids and the anal mucosa, which can no longer be pushed back into the anal canal. This indicates that the connective tissue and support structure in the anal area are severely weakened. An anal prolapse in Grade IV hemorrhoids is the most severe stage of hemorrhoidal disease and requires urgent medical treatment. The permanent bulging of the hemorrhoids is associated with significant discomfort and an increased risk of complications. Usually, surgical intervention is necessary to treat the hemorrhoids and mucosal prolapse and to improve the quality of life of those affected. Read more here about surgery for hemorrhoid treatment.

At what stage do itching, burning, and bleeding occur?

Hemorrhoids are a common health problem divided into four stages. Each stage is characterized by specific symptoms and severity levels, helping those affected better understand the progression of the condition. The following table provides a clear overview of the individual stages, including typical complaints and physical changes. This classification helps to better assess the condition and recognize when medical advice might be necessary. Read more here about bleeding hemorrhoids.

What does it mean when hemorrhoids are permanently prolapsed?

When hemorrhoids are permanently prolapsed, it is called Grade IV hemorrhoids, the most severe stage of hemorrhoidal disease. In this condition, the hemorrhoids are so enlarged and swollen that they protrude from the anal canal and cannot be pushed back either spontaneously or manually. This permanent prolapse is often referred to as anal prolapse, especially when a piece of the anal mucosa is also visible.

Permanently prolapsed hemorrhoids can cause significant discomfort, including:

• Severe pain caused by irritated or inflamed tissue.
• Persistent oozing and mucus discharge, leading to skin irritation.
• Bright red bleeding, as the sensitive mucous membrane is easily injured.
• Anal itching and anal burning due to constant friction and moisture.
• Foreign body sensation that makes sitting and walking uncomfortable.

A permanent prolapse usually requires surgical treatment, as conservative and minimally invasive measures are no longer sufficient at this stage to resolve the hemorrhoids. An early visit to the doctor is essential to avoid complications such as infections or tissue damage and to improve quality of life.

How do hemorrhoids develop from Grade I to Grade IV?

The development from Grade I to Grade IV is often a gradual process, favored by untreated complaints and stressful factors such as straining, overweight, or a sedentary lifestyle. Early measures such as a high-fiber diet, sufficient exercise, and targeted treatment can prevent progression and relieve symptoms. Hemorrhoids typically undergo a stepwise worsening if no appropriate treatment is given. The development from Grade I to Grade IV shows increasing strain on the vascular cushions and worsening symptoms.

What symptoms are typical for advanced hemorrhoids?

Hemorrhoids occur in different stages, which differ in the severity of symptoms and the type of changes. From mild discomfort such as itching and occasional bleeding to permanently prolapsed hemorrhoids causing intense pain, the condition worsens with each progression. A clear overview of the stages helps to better understand the symptoms and, if necessary, seek medical help early. The following table summarizes the four stages of hemorrhoids and describes their typical characteristics.

This overview shows the gradual worsening of hemorrhoids and makes clear how important early diagnosis and treatment are to prevent progression.

How common are hemorrhoids of the different stages?

The stages of hemorrhoids differ not only in the intensity of symptoms but also in their frequency and typical risk groups. This table summarizes the most important information to provide a quick overview of how often the individual stages occur and which groups of people are particularly affected.

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Find more detailed information here about the treatment of the respective stage of hemorrhoidal disease:

Hemorrhoids Grade I Treatment

Hemorrhoids Grade II Treatment

Hemorrhoids Grade III Treatment

Hemorrhoids Grade IV Treatment