Hemorrhoids classification
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Ahmed Younes M.B.B.CH [3]
Overview
Hemorrhoids are classified by anatomic origin relative to the dentate line as internal, external, or mixed. Internal hemorrhoids are further graded I–IV by degree of prolapse using the Goligher classification. Grade I bleeds without prolapse; grade IV is irreducible. Location and grade together determine the stepwise escalation from conservative therapy to office-based procedures to surgery. External hemorrhoidal disease is not graded and becomes clinically relevant mainly when acutely thrombosed.[1][2]
Classification
Vascular anal cushions are normal structures that contribute to continence and anal sensation. They are termed hemorrhoidal disease only when they enlarge, bleed, or prolapse symptomatically.[3] Classification has two axes:
- Anatomic location, which applies to all hemorrhoids.
- Grade of prolapse, which applies to internal hemorrhoids only.
Anatomic classification
| Type | Origin | Covering epithelium / innervation | Typical presentation |
|---|---|---|---|
| Internal | Internal hemorrhoidal plexus, above the dentate line | Columnar/transitional mucosa; viscerally innervated (insensate) | Painless bright-red rectal bleeding and/or prolapse. Usually not painful unless strangulated.[1][3][2] |
| External | External hemorrhoidal plexus, below the dentate line | Squamous epithelium (anoderm); somatically innervated | Painful mainly when acutely thrombosed or engorged; thrombosis presents as a painful, nonreducible protrusion at the anal verge. A residual skin tag may cause hygiene difficulty and perianal irritation.[1][3][4] |
| Mixed (combined) | Both plexuses, concurrently | Both components | Features of both internal and external disease. Recognized as a distinct category in current frameworks.[1][2] |
- Perianal pruritus is not specific to external hemorrhoids. Mucoid discharge from prolapsing internal hemorrhoids is a common cause.[1][5]
Grading of internal hemorrhoids (Goligher classification)
Internal hemorrhoids are graded by degree of prolapse. This four-grade system is the Goligher classification and is the one used by the ACG, ASCRS, and Cochrane sources.[3][2][6] Painless bleeding can occur with internal hemorrhoids of any grade.[7]
| Grade | Definition | Clinical implication |
|---|---|---|
| I | Prominent hemorrhoids that may bleed but do not prolapse | Conservative therapy first; office-based procedures if refractory[2][3] |
| II | Prolapse with straining or defecation; reduce spontaneously | Conservative therapy; rubber band ligation if refractory[3] |
| III | Prolapse with straining or defecation; require manual reduction | Office-based therapy (rubber band ligation) or surgery for larger or refractory disease[3][1] |
| IV | Chronically prolapsed; manual reduction ineffective (± strangulation) | Surgical; excisional hemorrhoidectomy is standard[2][8] |
- Grade distribution in endoscopic populations is weighted toward low grades. In a colonoscopy cohort of patients with internal hemorrhoidal disease, 72.9% were grade I, 18.4% grade II, 8.2% grade III, and 0.53% grade IV.[1]
Clinical application of the classification
- Assign both location and grade before treatment. Use external inspection at rest and with straining, digital rectal examination, and anoscopy; grade cannot be assigned reliably without visualizing prolapse.[1][2]
- Classification guides treatment only in symptomatic disease. Asymptomatic hemorrhoids of any grade require no treatment.[1]
- External and grade IV disease are not candidates for banding. Ligation below the dentate line causes severe somatic pain.[3][5]
- Significant pain should prompt reassessment for thrombosed external hemorrhoid, strangulated internal prolapse, or an alternative diagnosis such as anal fissure or anorectal abscess.[5]
- Do not attribute rectal bleeding to hemorrhoids by default. Bleeding from colorectal cancer is often misattributed to hemorrhoids; evaluate with colonoscopy when alarm features or unexplained bleeding are present.[2][4][9]
- Avoid over-grading. Do not mistake rectal mucosal prolapse or external skin tags for high-grade internal hemorrhoids.[5]
Limitations of the Goligher system
- It captures only prolapse. It does not capture bleeding severity, symptom burden, or external/mixed components, and it has inter-observer variability.[6]
- Symptom-based and supplementary systems have been proposed, but none has displaced Goligher grading in current guidelines.[6]
- Grade III management overlaps between office-based and surgical approaches. Evidence for Doppler-guided ligation is low quality.[3]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Ashburn JH (2025). "Hemorrhoidal Disease: A Review". JAMA. doi:10.1001/jama.2025.13083.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Hawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, Lightner AL, Paquette IM (2024). "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids". Dis Colon Rectum. 67 (5): 614–623. doi:10.1097/DCR.0000000000003276. PMID 38294832 Check
|pmid=value (help). - ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Wald A, Bharucha AE, Limketkai B, Malcolm A, Remes-Troche JM, Whitehead WE, Zutshi M (2021). "ACG Clinical Guidelines: Management of Benign Anorectal Disorders". Am J Gastroenterol. 116 (10): 1987–2008. doi:10.14309/ajg.0000000000001507. PMID 34618700 Check
|pmid=value (help). - ↑ 4.0 4.1 Arnold MJ, Smith D (2025). "Management of Hemorrhoids: Guidelines From the ASCRS". Am Fam Physician. 112 (6): 694–695.
- ↑ 5.0 5.1 5.2 5.3 Bharucha AE, Knowles CH, Malcolm A (2026). "An Evidence-Based Practical Review on Common Benign Anorectal Disorders: Hemorrhoids, Anal Fissure, Dyssynergic Defecation, and Fecal Incontinence". Gastroenterology. 170 (1): 50–69. doi:10.1053/j.gastro.2025.07.031.
- ↑ 6.0 6.1 6.2 Khan K, Lakshminarayan R, Yiasemidou M, et al. (2024). "Endovascular rectal artery embolisation (RAE) for symptomatic haemorrhoids". Cochrane Database Syst Rev. doi:10.1002/14651858.CD014829.
- ↑ Jacobs D (2014). "Clinical practice. Hemorrhoids". N Engl J Med. 371 (10): 944–951. doi:10.1056/NEJMcp1204188. PMID 25184866.
- ↑ Muldoon R (2020). "Review of American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids". JAMA Surg. 155 (8): 773–774. doi:10.1001/jamasurg.2020.0788.
- ↑ Chang TK, Ke TW, Hsieh PS, Chang SC, Hu WH, Huang CW, Chiang FF, Tsai HL, Liang JT, Liu CK, Wang JY (2025). "Taiwan society of colon and rectal surgeons' consensus on the management of hemorrhoidal disease". Int J Colorectal Dis. 40 (1): 224. doi:10.1007/s00384-025-05010-9. PMID 41162746 Check
|pmid=value (help).