Internal hemorrhoids: symptoms, grades and treatment

Internal hemorrhoids are swollen cushions inside the anal canal, above a boundary called the dentate line. They are the usual reason for bright red blood on the paper with little or no pain. If you also have a tender lump you can feel at the opening, that is a different problem, covered on the external hemorrhoids page. The shared overview of both types is on hemorrhoids.

Doctors grade internal hemorrhoids from 1 to 4 by whether the tissue stays inside or slips out. The grade is what decides between fiber, an office procedure, and surgery. This page walks through the grades, what each one feels like, and which treatment the trials and guidelines line up with.

Most internal hemorrhoids are grade 1 or 2. In a screening colonoscopy study, 277 of 380 people with hemorrhoids (72.89 percent) were grade 1, and 70 (18.42 percent) were grade 2. Grade 3 accounted for 31 people (8.16 percent) and grade 4 for 2 people (0.53 percent) ⁴.

Why internal hemorrhoids bleed and rarely hurt

The lining above the dentate line does not sense touch, pain, stretch, or temperature the way skin does. External hemorrhoids are covered by skin, which is why they ache. Internal hemorrhoids are covered by mucosa, the same family of lining as the rectum, which is why a bleed can be the only clue ².

A review of hemorrhoid grading and treatment defines hemorrhoids as normal anal cushions that have enlarged and moved downward. Internal ones start in the vascular cushion above the dentate line. The most common symptom in that review is rectal bleeding with a bowel movement ¹. NIDDK describes the same bleed as bright red blood on the stool, on the toilet paper, or in the bowl. A hemorrhoid that has fallen through the opening is called prolapse. Internal hemorrhoids that have not prolapsed are most often not painful. Once they prolapse, they may ache ³.

Bleeding from an internal hemorrhoid is usually a streak or a few drops with the stool, not a bowl full of blood. How to tell an expected streak from bleeding that needs a same-week visit is on bleeding hemorrhoids.

The four grades

The Goligher scale grades internal hemorrhoids by prolapse ¹.

Grade 4 also includes acutely thrombosed, incarcerated internal hemorrhoids, and circumferential prolapse that is stuck and clotted ¹. That is an emergency pattern, not a lump you watch for a week.

You can click through the same four grades here. The pictures are a simple side view, not a drawing of your body.

A doctor confirms the grade with your story and an exam. NIDDK’s diagnosis page describes a look at the outside, a gloved finger exam, and often anoscopy, a short lighted tube that shows the anal canal and lower rectum. Most people do not need anesthesia for that look ¹⁴. The grade is not something you should assign from blood volume alone. A heavy bleed can still be grade 1. A grade 3 hemorrhoid can bleed very little.

What to do for grade 1 and grade 2

Start with softer stools. A 2006 meta-analysis of seven fiber trials in 378 people with symptomatic hemorrhoids found a lower risk of symptoms that did not improve (relative risk 0.53) and about half the risk of bleeding (relative risk 0.50). The estimates for prolapse, pain, and itching were too wide to show a clear effect ¹⁰. So fiber is the bleeding treatment with the best evidence. It is a weak bet, on its own, for tissue that keeps slipping out.

NIDDK suggests fiber from food or a supplement such as psyllium, enough nonalcoholic fluid, no straining, and no long sits on the toilet ⁹. The best fiber supplements for hemorrhoids page compares powders and capsules. A standard psyllium powder is the usual first tub. Buyers often say to drink it before it thickens, and to take it with plenty of water.

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If bleeding continues, the next step is an office procedure. A meta-analysis of hemorrhoid treatment trials recommended rubber band ligation as the first procedure for grades 1 to 3. Banding worked better than sclerotherapy, an injection that scars the cushion, and people who had sclerotherapy or infrared coagulation were more likely to need another treatment. Hemorrhoidectomy, the operation that cuts the tissue out, had a better response than banding and also more pain and more complications. The authors kept surgery for people who did not improve after banding ⁵.

A family-medicine review reached a similar split. Rubber band ligation was described as the most effective office procedure for grades 1, 2, and 3. Surgery was described as the next step after office treatment failed, and also as initial care for some grade 3 and grade 4 hemorrhoids ⁸.

A Cochrane review of banding versus excisional surgery looked at this by grade. For grade 2, prolapse that goes back by itself, one small trial found no clear difference in symptom clearance (32 patients, relative risk 1.07). For grade 3, prolapse that needs a push, surgery did better (two trials, 116 patients, relative risk 1.23). Surgery also caused more postoperative pain (relative risk 1.94) and fewer people needed a repeat procedure after surgery. The authors’ practical line was banding for grade 2, and surgery for grade 3 or for a hemorrhoid that returns after banding. The trials were small and the methods were weak, so treat that split as a guide, not a rule ⁶.

What to do for grade 3 and grade 4

Grade 3 is the grade where reasonable doctors disagree, and the disagreement is in the trials. Banding is still offered first to many people, because a 2016 trial of artery ligation versus banding found that a course of banding can be enough, even though a single banding session recurs more often.

That trial enrolled people with grade 2 and grade 3 hemorrhoids. At one year, 87 of 176 people (49 percent) in the banding group had a recurrence, compared with 48 of 161 (30 percent) after Doppler-guided hemorrhoidal artery ligation. The gap was mostly extra procedures: 32 percent after banding had another procedure, versus 14 percent after ligation. Pain the day after the procedure averaged 3.4 out of 10 after banding and 4.6 after ligation. Serious events that needed a hospital stay were more common after ligation. The authors wrote that many patients would rather repeat a banding than have the more invasive operation ¹¹.

Grade 4 is outside that banding-first pattern. The tissue stays out and cannot be replaced. A 2016 review lists surgery as the initial treatment for symptomatic grade 4 hemorrhoids, and as an option for symptomatic grade 3 and for thrombosed internal hemorrhoids ⁷. The ASCRS patient page lists hemorrhoidectomy for grade 3 or 4 prolapse, for large external hemorrhoids, and for combined internal and external disease. Fewer than 10 percent of people seen for symptomatic hemorrhoids need an operation ².

If you and your surgeon are choosing between traditional excision and stapled hemorrhoidopexy, the eTHoS trial is the large comparison. It randomized 777 adults referred for surgery for grade 2 to 4 hemorrhoids. Stapled surgery was less painful in the first weeks. Over 24 months, quality of life was better after traditional excision (mean difference on the EQ-5D area-under-curve of 0.073, favoring excision). Serious adverse events occurred in 24 of 338 people (7 percent) after stapling and 33 of 352 (9 percent) after excision. The authors’ conclusion was to consider traditional excision over stapling when an operation is the plan ¹². Recovery week by week belongs to the surgery timeline on the procedures pages, not to a guess from this one.

A prolapsed internal hemorrhoid that has become trapped and clotted is not a home banding project. A clinical review describes first care for prolapsed, strangulated hemorrhoids as stool softeners, pain relief, rest, warm soaks, and ice packs until the acute swelling settles, with banding or excision of whatever remains later ⁸. Go in the same day if the pain is severe and the tissue will not go back.

Putting a prolapsed hemorrhoid back

The NHS says you can gently push a pile back inside if you can ¹⁶. That fits grade 2, which returns on its own, and grade 3, which returns with a push. It does not fit grade 4, which stays out by definition ¹.

Use a clean finger, a little lubricant if you have it, and stop if the pain spikes or the tissue will not stay in. The step-by-step, including when to quit, is on pushing a prolapsed hemorrhoid back in. Wash your hands before and after. If it prolapses again with every stool, that pattern is the reason to talk about banding rather than to keep pushing it back for months.

What banding feels like afterward

Only a clinician should place a band. NIDDK is explicit that you should never try this yourself. The band cuts off blood flow, the tissue shrivels, and it falls off most often within a week. A small scar holds the remaining cushion in place ⁹. The ASCRS patient page puts the fall-off at roughly 5 to 7 days, sometimes with a small amount of bleeding that day. One to three bands may be placed per visit, and more than one visit is common. A dull ache or pressure for 1 to 3 days is usual, and acetaminophen or ibuprofen is what that page suggests for it. People taking warfarin (Coumadin), heparin, or clopidogrel (Plavix) may not be candidates ².

A review of banding complications calls mild pain the most common problem. Bleeding that starts later, normally 10 to 14 days after the band, is the complication to plan for, and the risk is higher on antiplatelet or anticoagulant medicine. Major problems, including bleeding that will not stop, urinary retention, and pelvic infection, are uncommon. The same review notes that deaths from infection after banding have been reported, which is why fever, spreading pain, or feeling seriously ill after a band is a same-day call, not a wait-until-Monday symptom ¹³. What the visit itself is like is on rubber band ligation: what to expect.

Creams and suppositories are for mild symptoms while you wait for fiber to work, or while a band settles. NIDDK says doctors usually suggest store products for about a week ⁹. They do not replace banding for a hemorrhoid that keeps prolapsing. The full menu of home care, office procedures, and operations is on hemorrhoid treatment. Our picks of the best hemorrhoid suppositories cover the options for internal swelling.

When internal bleeding needs a doctor

NIDDK says to get care if rectal bleeding is happening, or if a week of home treatment has not helped ³. An exam is how the doctor tells an internal hemorrhoid from a fissure, a polyp, or inflamed bowel ¹⁴. Bleeding, pain, itching, seepage, prolapse, and mucus were reported equally often by people with hemorrhoids and by people without them in a review of the symptom research ¹⁷.

The US Preventive Services Task Force recommends colon cancer screening starting at age 45 for adults at average risk, through age 75, with an individual decision from 76 to 85 ¹⁵. If you are 45 or older and not up to date, ask for screening at the same visit. Who to call, and what the appointment includes, is on when to see a doctor for hemorrhoids. If you are bleeding and unsure what else it could be, read how to tell hemorrhoids from colon cancer.

If home care has quieted the bleeding and the tissue stays inside, keep the fiber going. The trials that measured bleeding more than once, usually at six weeks and at three months, kept showing the same fiber result over that stretch ¹⁰. A return of blood after a quiet month is a new symptom. Get it looked at rather than adding another week of cream.