Hemorrhoid surgery isn’t determined by physical size in centimeters. Instead, it’s based on a grading system that measures how far the hemorrhoid protrudes from the anal canal. Grades III and IV internal hemorrhoids are the ones most likely to need surgery, along with thrombosed external hemorrhoids that cause severe pain. Most people with Grade I or II hemorrhoids will never need an operation.
How Hemorrhoids Are Graded
Doctors classify internal hemorrhoids on a four-point scale based on prolapse, meaning how much the tissue drops out of place during or after a bowel movement. This grading system matters far more than measuring the hemorrhoid in inches or centimeters, because prolapse determines how much the hemorrhoid disrupts your life and whether non-surgical treatments can still work.
- Grade I: The hemorrhoid bulges into the anal canal during bowel movements but never comes out. You might notice some bleeding on toilet paper but can’t feel a lump.
- Grade II: The hemorrhoid pushes out of the anus during a bowel movement but slides back inside on its own afterward.
- Grade III: The hemorrhoid comes out during bowel movements and stays out until you push it back in with a finger.
- Grade IV: The hemorrhoid protrudes from the anus all the time and cannot be pushed back in.
External hemorrhoids sit outside the anal opening and aren’t graded on this scale. They become surgical candidates when a blood clot forms inside them, creating what’s called a thrombosed hemorrhoid: a firm, painful lump that can make sitting or walking miserable.
Which Grades Typically Need Surgery
Grade I and II hemorrhoids almost always respond to non-surgical approaches. Dietary changes, fiber supplements, better bathroom habits, and adequate water intake are the standard first-line treatment for all symptomatic hemorrhoids, according to the American Society of Colon and Rectal Surgeons’ 2024 guidelines. For Grades I and II that don’t improve with those changes, office-based procedures like rubber band ligation, infrared coagulation, or injection therapy are preferred over surgery because they offer similar results with fewer complications.
Grade III hemorrhoids occupy a middle ground. Some respond to rubber band ligation, particularly if they’re on the smaller end and prolapse only occasionally. But when Grade III hemorrhoids keep causing problems despite office-based treatment, or when they’re large and prolapse frequently, surgical removal enters the conversation.
Grade IV hemorrhoids are the clearest candidates for surgery. Because they permanently protrude and can’t be pushed back in, less invasive treatments rarely provide lasting relief. At this stage, patients typically deal with constant pain, persistent bleeding, and difficulty keeping the area clean. The 2024 ASCRS guidelines recommend that patients with symptomatic Grade III or IV hemorrhoids, especially those with both internal and external components, be referred for excisional hemorrhoidectomy.
Thrombosed Hemorrhoids: A Different Situation
A thrombosed external hemorrhoid doesn’t follow the grading system. It’s an external hemorrhoid where a blood clot has formed, and it can require urgent excision regardless of how large it is. The clot creates intense, sudden pain that peaks within the first 48 to 72 hours. Early surgical excision during that window tends to reduce acute pain, speed up healing, and lower the chance of recurrence. After three or four days, the pain often starts to subside on its own, and surgery becomes less beneficial relative to simply waiting it out with pain relief and sitz baths.
What Happens If You Delay Surgery
Grade IV hemorrhoids that go untreated can lead to a cascade of complications. Tissue that stays prolapsed outside the body is vulnerable to strangulation, where the anal sphincter cuts off blood flow. This can cause the tissue to die, leading to infection, abscess formation, or severe inflammation. Chronic bleeding from advanced hemorrhoids can also cause significant anemia over time, leaving you fatigued and short of breath.
Persistent prolapse exposes delicate tissue to bacteria from stool and urine, raising the risk of infection that can spread beyond the local area. Long-standing cases treated inappropriately can eventually lead to narrowing of the anal canal, making bowel movements permanently difficult. None of this means you need to rush into surgery at the first sign of trouble, but Grade IV hemorrhoids in particular tend to worsen rather than improve, and earlier treatment generally means a smoother recovery.
Types of Surgical Options
Excisional hemorrhoidectomy is the most definitive surgical option. The surgeon removes the hemorrhoidal tissue entirely, which gives the lowest recurrence rate of any approach. It’s the procedure most often recommended for Grade III and IV hemorrhoids, particularly when there’s a combined internal and external component. The tradeoff is a more painful recovery compared to less invasive alternatives.
Doppler-guided hemorrhoidal artery ligation is a newer option that can be considered instead of full excision for internal hemorrhoids. It uses ultrasound to locate the arteries feeding the hemorrhoid and ties them off, shrinking the tissue without removing it. Recovery is generally easier, though it may not work as well for the most advanced cases.
Stapled hemorrhoidopexy, which repositions prolapsing tissue using a circular stapler, is no longer recommended as a first-line surgical treatment. The ASCRS guidelines note it has marginal effectiveness compared to excision and carries a higher risk of postoperative complications. It’s reserved for cases where other methods have failed.
Some People Should Avoid Surgery
Certain conditions make hemorrhoid surgery riskier. People with Crohn’s disease or portal hypertension with rectal varices face significantly higher complication rates, so surgery is typically a last resort. Those with fecal incontinence need careful evaluation because hemorrhoidal tissue actually contributes to continence; removing it can make existing problems worse. Bleeding disorders don’t rule out surgery entirely, but they may change which technique the surgeon chooses.
Women with a rectocele (a bulging of the rectum into the vaginal wall) face a specific risk of obstructed bowel movements if any narrowing occurs after surgery. Stapled procedures in particular are discouraged in this group because of the risk of creating an abnormal connection between the rectum and vagina.
What Recovery Looks Like
After an excisional hemorrhoidectomy, the average recovery takes two to four weeks before you can return to normal daily activities and desk work. Strenuous exercise and heavy physical labor typically require six to eight weeks. Pain after surgery is significant for most people, particularly during the first week, and bowel movements can be uncomfortable as the surgical site heals. Sitz baths, stool softeners, and pain medication are standard during this period.
Less invasive surgical options like artery ligation generally involve a shorter, less painful recovery, though the exact timeline varies. Office-based procedures like rubber band ligation, which are used for lower-grade hemorrhoids, typically cause only mild discomfort for a day or two.