Internal hemorrhoids don’t have a fixed maximum size measured in centimeters, because doctors classify them by how far they prolapse (bulge out) rather than by diameter. A small internal hemorrhoid may sit invisibly inside the rectum, while the most severe cases push permanently outside the anus as a fleshy mass that can’t be pushed back in. Understanding the grading system gives you the clearest picture of how big these can get and what each stage looks and feels like.
How Doctors Measure Internal Hemorrhoids
Rather than pulling out a ruler, doctors use a four-grade scale based on prolapse, meaning how far the swollen tissue drops from its normal position inside the anal canal. This system, called the Goligher classification, has been the standard since 1980 and is still used in the most recent clinical guidelines from the American Society of Colon and Rectal Surgeons (2024). Each grade represents a meaningful jump in size and severity.
- Grade I: The hemorrhoid cushions are swollen but stay inside the anal canal. You can’t see or feel them from the outside. They may bleed during a bowel movement, but there’s no bulging tissue.
- Grade II: The hemorrhoid pushes below the internal boundary of the anal canal during straining, then slides back in on its own once straining stops. You might notice tissue briefly appearing during a bowel movement.
- Grade III: The hemorrhoid protrudes outside the anus during bowel movements or sometimes during physical activity, and it has to be manually pushed back in. At this stage, the tissue mass is large enough to see and feel clearly.
- Grade IV: The hemorrhoid is permanently prolapsed outside the anus and cannot be pushed back in at all. This is the largest an internal hemorrhoid gets, and the tissue can become quite bulky.
The visible portion of a prolapsed hemorrhoid typically looks like a soft, fleshy bump protruding from the anus. Cleveland Clinic notes the exact size varies from person to person. Some Grade IV hemorrhoids involve a single cushion, while others involve multiple cushions prolapsing together around the full circumference of the anal canal, creating a much larger mass of tissue.
What Each Grade Feels Like
Grade I hemorrhoids often cause no symptoms at all beyond occasional bright red blood on toilet paper or in the bowl. Because the tissue stays inside the rectum, where there are fewer pain-sensing nerves, you may not even know they’re there. Many people have them and never seek treatment.
As hemorrhoids progress to Grade II and III, symptoms shift. Bleeding may continue, but prolapse itself becomes the main complaint. Tissue that repeatedly bulges outward causes irritation, itching, and mucus discharge. Many people describe difficulty cleaning after a bowel movement or a persistent feeling that stool is stuck at the opening. Not everyone with larger internal hemorrhoids has significant bleeding. For some, the sensation of tissue protruding is the only symptom.
Grade IV hemorrhoids are often very painful, a notable change from the earlier grades. When prolapsed tissue stays outside the anus permanently, the surrounding muscle can clamp down on it and cut off its blood supply. This is called a strangulated hemorrhoid, and it causes extreme pain along with significant swelling. The tissue may turn darker in color and become firm to the touch. This is a situation that needs prompt medical attention.
Why They Keep Growing
Internal hemorrhoids are normal vascular cushions that everyone has. They become a problem when repeated pressure causes the blood vessels and surrounding connective tissue to stretch and swell. Chronic straining during bowel movements, prolonged sitting on the toilet, low-fiber diets, pregnancy, and heavy lifting all contribute. Over time, the connective tissue that anchors these cushions weakens, allowing them to slide further downward with each episode of straining. This is why hemorrhoids tend to progress through the grades if the underlying causes aren’t addressed.
The progression isn’t inevitable, though. Many people stay at Grade I or II for years, and lifestyle changes like increasing fiber and water intake can prevent worsening. Hemorrhoids that have already progressed to higher grades don’t typically shrink back down to earlier grades on their own, because the stretched tissue and weakened support structures don’t fully recover.
How Treatment Changes With Size
The grade of the hemorrhoid directly determines what treatments are appropriate, which is why the classification matters so much.
Grade I and II hemorrhoids usually respond to conservative measures: more dietary fiber, adequate hydration, and avoiding prolonged straining. If those steps aren’t enough, an office-based procedure called rubber band ligation is the preferred next step for Grades I through III. A tiny band is placed around the base of the hemorrhoid to cut off blood flow, causing the tissue to shrink and fall off within a few days. Other office procedures, like infrared treatment, are also options but tend to have higher failure rates.
Grade III hemorrhoids that don’t respond to banding, and most Grade IV hemorrhoids, typically need surgical removal. A conventional hemorrhoidectomy cuts away the excess tissue and is the most effective option for large or recurring hemorrhoids. Another approach repositions the prolapsed tissue back to its normal location by removing a ring of tissue above the hemorrhoid. Recovery from surgery takes longer than office procedures, usually a few weeks, but the recurrence rate is lower for advanced cases.
A newer technique that ties off the arteries feeding the hemorrhoid may work well for Grade II and III hemorrhoids, with the advantage of less pain and faster recovery compared to traditional surgery.
When Size Signals Something Else
Because internal hemorrhoids sit inside the anal canal, you can’t always assess their size yourself. What feels like a large hemorrhoid could be something else entirely. Doctors recommend a digital rectal exam to rule out other conditions, and anoscopy (a quick look inside the anal canal with a small scope) to directly visualize the hemorrhoids and confirm their grade. This is especially important if you’re over 40 and experiencing new rectal bleeding, since other conditions can mimic hemorrhoid symptoms. A proper evaluation takes just a few minutes and gives you a clear answer about what you’re dealing with and how advanced it is.