- Grade 1 protrudes into the anal canal but does not prolapse outside the anus.
- Grade 2 protrudes out of anal canal with defecation / straining but spontaneously reduces.
- Grade 3 prolapses out of the anal canal with defecation / straining but can be manually reduced.
- Grade 4 prolapses into anal canal and is unable to be reduced.
Clinical manifestations of symptomatic hemorrhoids depend on whether internal or external hemorrhoids are present. Internal hemorrhoids are not sensitive to pain or temperature so they often present with painless rectal bleeding, prolapse, passage of mucus in stool, pruritus, or leakage of rectal contents. External hemorrhoids are covered by squamous epithelium, which contains pain receptors; therefore, symptoms include rectal pain, swelling, and pruritus.
Symptoms can last days to weeks and often require treatment with a high-fiber diet or fiber supplementation, sitz baths, and topical creams. If symptoms persist, these patients may require band ligation or surgery. Symptomatic hemorrhoids can recur in the future.