Most clinicians use the grading system proposed by Banov and colleagues in 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches, as follows:
Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse
Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating, but reduce spontaneously when straining ceases (ie, return to their resting point by themselves)
Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction (ie, they require manual effort for replacement into the anal canal)
Grade IV hemorrhoids chronically prolapse and cannot be reduced; these lesions usually contain both internal and external components and may present with acute thrombosis or strangulation
For more on grading hemorrhoids, read here.
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