What Are Stage 4 Hemorrhoids? Symptoms & Treatment

Stage 4 hemorrhoids are the most advanced grade of internal hemorrhoidal disease, defined by tissue that protrudes from the anal canal and cannot be pushed back inside. Unlike earlier grades, where swollen tissue either stays internal or can be manually repositioned, grade IV hemorrhoids are permanently prolapsed and irreducible, meaning they hang outside the anus at all times. This distinction matters because it almost always pushes treatment beyond conservative measures and toward surgery, though the specifics of which surgery, and how urgently, depend on what symptoms you are dealing with.

What Makes Stage 4 Different From Earlier Grades

Hemorrhoids exist on a four-point grading scale originally developed by the surgeon John Goligher. Grades I and II describe internal hemorrhoids that either bleed without prolapsing or prolapse during straining but retract on their own. Grade III hemorrhoids prolapse and require manual pushing to get them back inside. Grade IV hemorrhoids prolapse and stay out permanently; they are irreducible.¹ That inability to reduce them is the defining feature, and it changes both the symptom profile and the treatment approach considerably.

At the tissue level, what you are looking at is a breakdown of the normal support structures inside the anal canal. The anal cushions, which are spongy pads of blood vessels and connective tissue that help with continence, undergo abnormal dilation and distortion of their blood vessels along with destructive changes to the connective tissue holding everything in place.² In advanced disease, imaging and tissue studies show obvious structural damage: the elastic layers within blood vessel walls rupture and degrade, supporting muscle fibers become thickened and distorted, and abnormal connections form between arteries and veins within the cushion.³ In plain terms, the tissue has stretched, weakened, and reorganized itself to the point that it can no longer hold itself inside the canal.

Symptoms You Can Expect

The most obvious symptom is the prolapse itself: a visible, often fleshy or purplish lump protruding from the anus that does not go back in. But the symptom experience goes well beyond that. Bleeding is common, ranging from streaks on toilet paper to dripping into the bowl. Mucous discharge from the exposed lining is typical and can lead to persistent perianal moisture and irritation. Itching and soreness around the anus are frequent complaints, driven partly by the skin being constantly in contact with mucus and stool.

Pain is not always a dominant feature of uncomplicated grade IV hemorrhoids, which surprises many people. Internal hemorrhoidal tissue sits above the nerve-rich area of the anal canal, so prolapsed tissue itself can be more uncomfortable than acutely painful. The situation changes dramatically, however, when a complication like thrombosis or strangulation occurs. Thrombosed hemorrhoids develop a blood clot inside the prolapsed tissue, causing sudden, intense pain and a firm, swollen lump. Strangulation happens when the anal sphincter traps the prolapsed tissue, cutting off its blood supply. Both of these are considered acute hemorrhoidal crises and can require urgent treatment.⁴

The symptom burden has real effects on daily life. Research on quality of life in hemorrhoidal disease shows that patients with a high symptom load score lower on physical health measures compared to the general population, and that these scores improve after surgical treatment.⁵ Interestingly, it is the patient’s experience of symptoms, not the surgeon’s grading of how severe the anatomy looks, that most closely tracks with reduced quality of life. Two people with the same grade can have very different levels of misery.

How Stage 4 Hemorrhoids Are Diagnosed

Diagnosis is usually straightforward. A physician will perform a visual inspection of the anus, typically with you in a side-lying or knee-chest position, along with a digital rectal exam to check for other problems and assess sphincter function. Because prolapsed tissue can sometimes be confused with a full-thickness rectal prolapse, where the entire wall of the rectum telescopes outward, having you strain on the toilet during the exam helps the examiner distinguish between the two conditions.⁶ Further testing with a scope is sometimes added to rule out other sources of bleeding, particularly in older adults or those with risk factors for colorectal disease.

Why Surgery Is Usually Necessary

Conservative treatments like fiber supplements, stool softeners, sitz baths, and topical creams are the go-to approach for grade I and II hemorrhoids. Phlebotonics, a class of drugs that aim to strengthen blood vessel walls and improve venous tone, are sometimes used for milder disease and during flare-ups, but the evidence supporting them relates mostly to early-stage hemorrhoids and acute thrombotic episodes.⁷ By the time tissue has permanently prolapsed, these measures can help manage symptoms around the edges but rarely solve the underlying problem.

Dietary changes still matter even at stage 4. In one study of patients with grade II through IV disease, a dietary regimen resolved persistent constipation in the vast majority within three to four weeks.⁸ That matters because straining is a major driver of hemorrhoidal progression. But fixing constipation alone will not retract tissue that has already lost its structural support. For grade IV, surgery is the definitive treatment, and the choice of procedure is where decisions get more nuanced.

Excisional Hemorrhoidectomy

The gold standard for stage 4 hemorrhoids remains excisional hemorrhoidectomy, where the prolapsed tissue is physically cut out. There are two main variants: the open technique (Milligan-Morgan), where the wound is left open to heal from the inside out, and the closed technique (Ferguson), where the wound edges are stitched together.

Head-to-head comparisons of the two approaches show broadly similar outcomes with some trade-offs. In one trial, the closed technique offered faster wound healing, with about three-quarters of patients healed at three weeks versus under a fifth in the open group. Pain immediately after surgery and at the first bowel movement was also lower in the closed group.⁹ Another study comparing the two techniques specifically in grade IV patients found similar hospitalization times and postoperative pain levels, though the closed method showed a trend toward faster overall wound healing while also trending toward higher wound infection rates.¹⁰ A third comparison found that all patients in the closed group had complete wound healing at two weeks, versus about half of the open group, though patients undergoing the closed technique reported more pain.¹¹

The bottom line on open versus closed is that neither is clearly superior across all outcomes. Closed hemorrhoidectomy tends to heal faster, but open hemorrhoidectomy may involve less acute pain in some settings and carries a lower risk of wound breakdown. Your surgeon’s experience and preference often matter as much as the technique itself.

Stapled Hemorrhoidopexy and Its Limitations at Grade IV

Stapled hemorrhoidopexy takes a different approach: instead of cutting out the prolapsed cushions, a circular stapling device removes a ring of tissue higher up in the anal canal and staples the remaining tissue back into its normal position. It is generally less painful in the short term and allows a faster return to normal activity. In one long-term study comparing stapled hemorrhoidopexy to the Milligan-Morgan technique for grade IV disease, pain scores on the day of surgery were considerably lower in the stapled group, and patients returned to activity about half a week sooner.¹²

The catch is recurrence. The same study found that stapled hemorrhoidopexy patients had persistent bleeding in about 14% of cases versus none in the excisional group, tenesmus (a sensation of incomplete evacuation) in about a third of stapled cases versus none, and a slightly higher relative risk of the hemorrhoids coming back. A meta-analysis pooling several trials that looked specifically at grade IV hemorrhoids found an overall recurrence rate of about 20% after stapling versus no recurrences at all after conventional hemorrhoidectomy.¹³ A more recent single-center analysis found a recurrence rate of about 24% in grade IV patients after stapling.¹⁴ Network meta-analyses comparing multiple surgical approaches have confirmed that stapled hemorrhoidopexy and transanal dearterialization show the highest recurrence rates among the procedures studied.¹⁵

For grade IV disease specifically, the evidence leans toward excisional hemorrhoidectomy when long-term durability matters most. Stapling remains a reasonable option if short-term recovery is the priority and the patient understands the higher chance of recurrence.

Doppler-Guided Dearterialization

Doppler-guided hemorrhoidal artery ligation with rectoanal repair, often abbreviated HAL-RAR, uses an ultrasound probe inserted into the anal canal to locate the arteries feeding the hemorrhoidal cushions. Those arteries are then sutured shut, reducing blood flow to the swollen tissue, and a running stitch lifts the prolapsed tissue back into position. It is considered a less invasive option with less postoperative pain than traditional hemorrhoidectomy.

For grade IV hemorrhoids, the results are mixed. One study of 100 consecutive grade IV patients concluded that HAL-RAR was safe and effective and should be considered a valid option.¹⁶ However, a more recent institutional analysis found that grade IV disease was independently associated with roughly 3.6 times the odds of symptomatic recurrence after HAL-RAR compared to lower grades, and patients with grade IV hemorrhoids were significantly less likely to be discharged the same day. The procedure was also about seven times more likely to require intraoperative conversion to an excisional hemorrhoidectomy when grade IV tissue was involved.¹⁷ Some guidance suggests that HAL-RAR with mucopexy can be used for grade IV hemorrhoids unless they are fixed and fibrotic, which is a subset where the tissue has become too rigid for repositioning.¹⁸

Energy-Based Techniques

Newer surgical approaches use energy devices to seal and cut tissue with less bleeding and potentially less pain than traditional scalpel-and-cautery methods. Two that get the most attention are LigaSure hemorrhoidectomy, which uses bipolar radiofrequency energy to seal blood vessels before cutting, and laser hemorrhoidoplasty, which uses a diode laser fiber inserted directly into the hemorrhoidal tissue to shrink it from within.

A prospective trial comparing laser hemorrhoidoplasty, LigaSure hemorrhoidectomy, and conventional diathermy hemorrhoidectomy for grade III and IV disease found that both the laser and LigaSure approaches produced significantly less postoperative pain than conventional diathermy, with shorter operative times, less blood loss, and faster recovery.¹⁹ A separate comparative analysis found that patients treated with laser hemorrhoidoplasty had markedly lower pain scores on day one compared to LigaSure patients and returned to daily activities in about two days versus nearly five.²⁰ The evidence on long-term recurrence rates with these newer energy-based methods specifically in grade IV patients is still building, and they have not yet displaced excisional hemorrhoidectomy as the reference standard for the most advanced disease.

Managing Pain After Surgery

Postoperative pain is the most dreaded aspect of hemorrhoid surgery for most patients, and for good reason: the anal canal is densely innervated, and the wounds are in an area subjected to repeated mechanical stress with every bowel movement. Pain management strategies have been studied extensively and generally involve a combination of approaches.

Local anesthetic techniques are a major component. Options include nerve blocks targeting the pudendal nerve or the tissue surrounding the anus, along with direct infiltration of long-acting anesthetic agents into the surgical wound. Adding agents like morphine or midazolam to spinal anesthesia has been shown to extend pain control in the first 12 to 24 hours after surgery.²¹ Beyond anesthetic blocks, postoperative regimens typically include oral pain medications, stool softeners to minimize straining at the first bowel movement, and sitz baths. Keeping stools soft is arguably as important as any painkiller in the first week.

Complications and What to Watch For

All hemorrhoid surgeries carry a risk of complications, though serious ones are uncommon. Urinary retention, the temporary inability to urinate after surgery, is one of the most frequent issues and affects roughly 15 to 20% of patients in some series.¹⁰ It usually resolves within a day or two, occasionally requiring a temporary catheter. Postoperative bleeding can occur early, within the first day or two, or in a delayed fashion about a week later when scabs separate from the wound.

Anal stenosis, a narrowing of the anal canal from scarring, is a feared late complication, especially when large amounts of tissue are removed. Network meta-analyses suggest that transanal dearterialization and stapled approaches produce less stenosis than open or Harmonic-scalpel hemorrhoidectomy, while tissue-selecting therapy stapler techniques appear to have the lowest rates of both stenosis and urinary retention.²² Fecal incontinence after hemorrhoidectomy is a concern, particularly because the surgery itself can reduce anal resting pressures. One study found that maximum anal pressures dropped by about a third after hemorrhoidectomy.²³ In most cases this does not translate into clinically significant leakage, but patients with borderline sphincter function before surgery face a higher risk.

Hemorrhoids During Pregnancy

Pregnancy is a common trigger for hemorrhoidal disease because of increased pelvic blood flow, hormonal changes that relax vein walls, and the mechanical pressure of a growing uterus on pelvic veins. Most pregnancy-related hemorrhoids are managed conservatively, with dietary changes, topical treatments, and stool softeners. Surgery during pregnancy is generally avoided unless complications like severe thrombosis or strangulation make it unavoidable. One study of 70 pregnant women with hemorrhoids across all four stages found that an individualized treatment approach led to symptom resolution in about 10 days for early-stage disease and about 18 days for stages 3 and 4, with no relapses within a year after completing treatment.²⁴ Definitive surgical treatment, if needed, is typically deferred until after delivery and recovery.

Recovery and Quality of Life After Treatment

One of the most underappreciated aspects of stage 4 hemorrhoids is the psychological toll. The constant sensation of prolapsed tissue, anxiety about bleeding, discomfort sitting for long periods, and embarrassment about the condition all contribute to reduced well-being. Research confirms that quality of life measures, covering physical health, psychological health, and social relationships, all improve significantly after surgery. In one study tracking patients at two and four weeks after surgery, every measured domain showed substantial gains between those two time points, with social relationship scores nearly doubling.²⁵

Recovery timelines depend heavily on the procedure. After conventional open hemorrhoidectomy, most people return to work within three to four weeks, with complete wound healing taking longer. Closed techniques and energy-based methods tend to shorten this. Laser hemorrhoidoplasty patients in one study were back to daily activities in about two days on average.²⁰ The first bowel movement after surgery is almost universally described as the hardest part. Stool softeners started before surgery and continued afterward, adequate hydration, and a high-fiber diet are non-negotiable during recovery regardless of the procedure performed.

Long-term prevention after surgical treatment focuses on the same lifestyle factors that would have slowed progression in the first place: maintaining soft, regular bowel movements through adequate fiber and fluid intake, avoiding prolonged straining and excessive time on the toilet, and staying physically active. None of these guarantee that hemorrhoids will never return, but they meaningfully reduce the odds, especially after excisional procedures where recurrence rates are already low.