Haemorrhoids: The Four Grades and Which Treatment Fits Which
Haemorrhoids are dilated veins at the end of the large bowel and everybody has them, because they are a normal part of the anatomy. We speak of disease only when they enlarge and start to bleed, itch, hurt or prolapse. What determines treatment is not how much the symptoms bother you but the grade. This article covers the four grades, what is done at each, and when sclerotherapy is enough and when it is not.
The four grades of haemorrhoidal disease
The classification applies to internal haemorrhoids and is based on whether the cushion prolapses through the anal opening and whether it returns on its own.
| Grade | What happens | Usual treatment |
|---|---|---|
| I | The cushions stay inside and do not prolapse. The usual sign is painless bright red bleeding on passing stool. | Change of habits and diet, topical treatment, sclerotherapy. |
| II | Prolapses on straining but returns by itself. | Sclerotherapy or banding, plus a change of habits. |
| III | Prolapses and returns only if pushed back by hand. | Usually surgical treatment; office procedures rarely give a lasting result. |
| IV | Permanently prolapsed and cannot be reduced. Thrombosis is possible. | Surgical treatment. |
One detail surprises patients and is worth remembering: internal haemorrhoids of grade I and II often do not hurt, because the mucosa above the dentate line has no pain receptors. So the absence of pain does not mean the situation is harmless, and severe pain usually points to something else, as a rule an anal fissure or a thrombosed external cushion.
Blood in the stool is never assumed
This is the most important part of the article. Bright red blood on the paper or in the bowl most often does come from haemorrhoids, but exactly the same symptom is produced by an anal fissure, inflammatory bowel disease, polyps and bowel cancer. None of those can be excluded without an examination.
So bleeding is not treated with over-the-counter haemorrhoid creams on your own initiative. See a doctor without delay if the bleeding comes with any of the following: dark blood or blood mixed into the stool, a change in bowel habit lasting weeks, weight loss, weakness or anaemia, age over 45, or bowel cancer in the family.
What the examination involves
A proctological examination starts with a conversation about your symptoms, followed by examination with anoscopy, a short inspection of the end of the bowel with an instrument that gives the doctor a direct view. It takes a few minutes and for most patients is uncomfortable but not painful. Based on the findings you get the grade, the diagnosis and a treatment proposal straight away, so there is no waiting and no second appointment just to hear the result.
Special preparation is usually not required. At Miren Medic the examination is performed by Dr Branimir Nešković, surgical oncologist, with no referral needed. Read more about the service on the proctologist Belgrade page.
Sclerotherapy: when it is enough
Sclerotherapy is an office procedure in which an agent is injected into the mucosa above the haemorrhoidal cushion, causing controlled scarring. That cuts off the blood supply, the cushion shrinks and the bleeding stops. It is done under local anaesthesia, takes a short time, needs no hospital stay and none of the preparation a classic operation requires. You go home straight after.
It gives the best results in grades I and II, particularly when bleeding is the leading symptom. In grades III and IV success is considerably lower, because sclerotherapy does not resolve prolapsing tissue, so surgical treatment is planned instead. Some patients need more than one session, and the method does not rule out later surgery if the condition worsens.
An honest conclusion patients rarely hear: sclerotherapy resolves the symptoms but does not change the habits that caused the problem. Without that, the trouble returns, however successful the procedure was.
What actually helps day to day
- Fibre and water. Soft stool is the only real prevention. Vegetables, fruit, whole grains and enough fluid do more than any cream.
- No straining. Go when the urge comes and do not postpone, because the stool only hardens further.
- Keep it short. No phone, no sitting for ten minutes. Prolonged sitting raises pressure in the veins.
- Movement. Long periods of sitting and standing make symptoms worse, so regular breaks and walking help.
- Hygiene without harsh rubbing. Lukewarm water instead of dry paper, and no perfumed wipes.
Ointments, suppositories and sitz baths soothe symptoms and have their place, but they do not shrink the cushion and do not address the cause. If symptoms persist for more than two weeks despite them, an examination is the next step.
Prices
| Service | Price |
|---|---|
| Proctological examination with anoscopy | 14.000 RSD |
| Sclerotherapy of haemorrhoids under local anaesthesia | 14.000 RSD |
| Surgical oncology consultation (Dr Branimir Nešković) | 10.000 RSD |
| Incision of a perianal abscess under local anaesthesia | 60.000 RSD |
| Pilonidal sinus surgery under local anaesthesia | 50.000 to 96.000 RSD |
Frequently asked questions
How many grades of haemorrhoids are there?
Four. In grade I the cushions do not prolapse, in grade II they prolapse on straining and return by themselves, in grade III they return only when pushed back by hand, and in grade IV they are permanently outside. The grade is established by examination with anoscopy, and it, rather than the severity of symptoms, determines treatment.
Do haemorrhoids resolve on their own?
Milder symptoms can settle with a change of diet, more fibre and avoiding straining. Haemorrhoids that bleed or keep coming back do not resolve on their own and need examination. In grades I and II sclerotherapy solves the problem in the office, without a classic operation.
Is sclerotherapy of haemorrhoids painful?
It is done under local anaesthesia and for most patients is uncomfortable rather than painful. It takes a short time, requires no hospital stay, and you go home straight after with instructions for care and a follow-up appointment.
Blood in the stool: is it definitely haemorrhoids?
No. Bright red blood most often comes from haemorrhoids or an anal fissure, but the same symptom is produced by inflammatory bowel disease, polyps and bowel cancer. Bleeding is therefore never assumed, it is examined, particularly if the blood is dark, if bowel habit has changed, or if you are over 45.
Do I need a referral to see a proctologist?
No. A proctological examination at Miren Medic is booked directly, without a referral, and special preparation is usually not needed. If preparation is required, you receive instructions when you book.
Book a consultation
If you have bleeding, itching or the feeling of a lump, book a proctological examination at Miren Medic. Examination with anoscopy, the diagnosis and a treatment proposal come in a single appointment, discreetly and without a referral, and sclerotherapy is performed in the office under local anaesthesia.
