These sit inside the rectum, above the point where you can feel much. That is why the usual story is bleeding with no pain, and why the grade has to be established by looking rather than by asking.
Internal hemorrhoids are staged one to four by how far they have moved from where they started. Grade one has not come down. Grade two comes down and goes back by itself. Grade three comes down and has to be pushed back. Grade four stays down.
That single number decides nearly everything that follows. Grades one to three that have not settled with conservative measures are what office procedures are built for, and banding is well regarded for grade two in particular. What you have already tried matters as much as the number itself.
Grade four is a different conversation, and usually a surgical one. The grades guide goes through each stage at more length, and in office against surgery sets out where the line falls and what recovery looks like on each side of it.
Hamilton grading
How grading works
Establishing the Hamilton grade
History first
Whether there is bleeding, whether anything comes down, and whether it goes back on its own. That last answer narrows it immediately.
The anoscopy
A couple of minutes with an anoscope shows which columns are involved and how far each has moved from its original position.
The grade, said out loud
You are told the number rather than left to infer it, because every option on the table follows from it.
Matching the option
Grades one to three that have not settled go to office procedures. Grade four is discussed as a surgical question.
Painless bleeding
Why these bleed without hurting
The lining above the anal canal has very little in the way of pain sensation, which is why an internal hemorrhoid can bleed steadily and still not hurt. People often describe bright red blood on the paper or in the bowl with nothing else going on at all.
That absence of pain is reassuring in the wrong direction. It is the main reason internal hemorrhoids go unexamined for months, and bleeding is the one symptom where months of waiting is the expensive choice. The red flags page lists what moves it past this clinic.
Pain, when it does appear, usually means something else has joined in: a fissure, or a clot in an external hemorrhoid. Fissures and thrombosis both hurt in ways internal disease normally does not. If yours does hurt, say so early, because it changes what the examination is looking for.
I to IIIGrades suited to office work
Painless bleedingUsual presentation
A surgical questionGrade four
Related
What else Hamilton patients are checked for
The conditions that overlap with internal disease, and the procedures that treat it once the grade is known.
What people ask once they have been told there is something inside rather than outside.
Usually by what is missing. Bleeding with no pain, and nothing you can feel from outside, points inwards. It is still confirmed with an anoscope, because external disease and fissures can present quietly too.
Not normally, unless it has prolapsed far enough to come down. That is part of why grading needs an instrument: the thing being graded is above where your own fingers reach.
Often not. Grade one that is not bleeding much usually responds to more fibre, more fluid and less straining, and a procedure would be treating something that was going to settle anyway.
No, but it is the most commonly used and is well regarded for that grade specifically. Infrared coagulation and sclerotherapy are both alternatives, chosen on size and position rather than preference.
It can, in both directions. Conservative measures sometimes move a grade two back toward one, and years of straining can move a three toward a four. The grade is re-checked, not assumed.
Because it no longer reduces, so there is nothing for a band to pull back into place. At that point removing the tissue is the option that actually addresses what is there.
The examination takes a couple of minutes and gives you the one number every option depends on. Tell us whether there is bleeding and how long it has gone on.
