What Are Stage 4 Hemorrhoids and How Are They Treated?

Everyone has soft cushions of blood vessels inside the anus. Hemorrhoids are what happen when those cushions swell and slip out of place. Stage 4 is the furthest point on that slide: the tissue sits outside the body for good and no longer goes back in. Only a small share of people with hemorrhoids ever get there.1PubMed. The prevalence of hemorrhoids in adults By then, treatment usually shifts from creams and diet changes to removing the tissue, and the choice of surgery affects how painful recovery is and how likely the problem is to return.

How Doctors Grade Hemorrhoids and What Makes Stage 4 Different

Doctors sort hemorrhoids into four grades (also called stages) based on how far the tissue slips during a bowel movement.

Living with stage 4 usually means a soft, lumpy bulge you can feel at the anus all the time, not just after a bowel movement. Tissue that sits outside tends to stay damp, so moisture, mucus, and itching are common. Bleeding can recur, and if it is heavy or frequent it can leave you tired from low iron.6Academic Medicine & Surgery. Irreducible Grade IV Internal Hemorrhoids With Segmental Mucosal Prolapse Sitting and wiping may be uncomfortable, though uncomplicated stage 4 is often not sharply painful.

Your grade matters because doctors traditionally sent stages 1 and 2 to medicine or office procedures and stages 3 and 4 to surgery.7PubMed Central. A New Classification for Hemorrhoidal Disease: The Creation of the “BPRST” Staging and Its Application in Clinical Practice The grade is set by looking and a gentle exam, sometimes while you lie on your left side.8Academic Medicine & Surgery. Irreducible Grade IV Internal Hemorrhoids With Segmental Mucosal Prolapse How much your symptoms bother you counts as much as the grade when choosing treatment.

Stage 4 internal hemorrhoids are different from external hemorrhoids, which form under the skin around the anus, and from skin tags, which are soft flaps of leftover skin. Because these lumps can look alike, an exam is the way to tell which one you have.

When Stage 4 Hemorrhoids Become an Emergency

Because stage 4 tissue sits outside, swelling can lock it in place and squeeze off its blood flow.9Seminars in Colon and Rectal Surgery. Elective surgery for hemorrhoidal complaints: The decision to operate The anal muscle ring can grip tissue that is already swollen and outside, acting like a tourniquet. Once blood can flow in but not easily out, the tissue swells more, which tightens the squeeze further.

A trapped hemorrhoid like this fills with clots and swelling and can’t be pushed back.10PubMed Central. Optimal Treatment of Symptomatic Hemorrhoids Left untreated, the tissue can break down into open sores or die.11Seminars in Colon and Rectal Surgery. Elective surgery for hemorrhoidal complaints: The decision to operate12EMOttawa Blog. The Bottom Line: Hemorrhoids and Anal Fissures in the ED

Ordinary stage 4 tissue is pink-purple and swollen, while trapped tissue turns dark, gray, or black and smells foul.13EMOttawa Blog. The Bottom Line: Hemorrhoids and Anal Fissures in the ED Pain that jumps from mild to severe over a few hours is a warning sign. Don’t try to force a hard, painful lump back in, since that can worsen the injury. Heavy bleeding that soaks pads or makes you dizzy also needs urgent care.

Emergency departments usually call in a surgeon for a trapped stage 4 hemorrhoid.14EMOttawa Blog. The Bottom Line: Hemorrhoids and Anal Fissures in the ED When tissue has died, surgery is needed urgently, and the surgeon makes that call rather than the patient.15Seminars in Colon and Rectal Surgery. Elective surgery for hemorrhoidal complaints: The decision to operate Dead tissue is generally removed in an operation the same day or soon after.

Ruling Out Other Causes Before Treatment

Hemorrhoids are the most common cause of blood from the bottom.16Diseases of the Colon & Rectum. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids But colon cancer, inflammatory bowel disease, and pouches in the colon wall can also cause it.17Diseases of the Colon & Rectum. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids Bleeding wrongly blamed on hemorrhoids is a common way a cancer diagnosis gets missed.18Diseases of the Colon & Rectum. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids

A colonoscopy is advised if the doctor can’t see an obvious bleeding source.19Diseases of the Colon & Rectum. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids It is also advised if you have belly pain, bloating, or new or worsening constipation.20Diseases of the Colon & Rectum. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids Bleeding that continues after hemorrhoid treatment should be investigated.21Diseases of the Colon & Rectum. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids If you’re due for routine colon cancer screening, ask whether it can be done now.

A bulge can also be rectal prolapse, where the lower bowel itself slides out. That is a different problem with different surgery. Hemorrhoids usually come out as separate lumps in three or four clusters, while prolapse usually looks like a smooth ring of folds all the way around. A doctor’s exam settles it, so don’t self-diagnose a bulge.

At the visit, say how long the bulge has been out and whether it ever went back in. Describe how often you bleed and what the blood looks like. Mention any family history of colon cancer or bowel disease.

Why Surgery Is Usually Needed and the Standard Operation

Rubber band ligation, the common office treatment, is almost never right for stage 4.22Forest Hills Gastroenterology. Hemorrhoid Ablation | Gastroenterologist in Forest Hills, NY Banding works best on a modest amount of tissue inside the canal, where a band can cut off the blood supply and let it fall away. Stage 4 tissue often includes a large amount of skin-covered tissue outside, and the skin there has pain nerves that a band would trigger. A band could cause severe pain and leave much of the problem untouched.

Fiber, fluids, and not straining are recommended for all stages, though proof that they treat hemorrhoids is limited.23PubMed Central. Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study They help with comfort and with preventing recurrence, not with reversing stage 4. After surgery they also protect healing, since a hard stool can disturb a fresh wound.

The standard operation is a hemorrhoidectomy, which cuts away the swollen tissue. In the open version the wound is left to heal on its own, and in the closed version it is stitched. Across trials, the closed method caused somewhat less pain, healed faster, and halved the bleeding risk.24PubMed. Milligan-Morgan (Open) Versus Ferguson Haemorrhoidectomy (Closed): A Systematic Review and Meta-Analysis of Published Randomized, Controlled Trials It takes a few minutes longer in the operating room.25PubMed Central. An evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat University Hospital Jamshoro, Hyderabad, Pakistan Hospital stay, infection, and the chance of hemorrhoids returning were about the same either way.26PubMed. Milligan-Morgan (Open) Versus Ferguson Haemorrhoidectomy (Closed): A Systematic Review and Meta-Analysis of Published Randomized, Controlled Trials Removal surgery is still the treatment least likely to let hemorrhoids come back.27PubMed Central. Stapled versus conventional surgery for hemorrhoids

The operation is usually done under general or spinal anesthesia, often as a day case or short stay. Each swollen cluster is removed while the anal muscle is protected. You go home with pain medicine, stool softeners, and wound care instructions.

Less Invasive Alternatives and Their Trade-Offs

The stapled procedure (stapled hemorrhoidopexy) uses a circular stapler to lift the hemorrhoids back inside rather than cut them out.28PubMed Central. Stapled versus conventional surgery for hemorrhoids It works higher up in the canal instead of in the sensitive skin near the anus, which helps explain the milder early pain. People feel better in the first three weeks than people who had removal surgery.29PubMed Central. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial From about six weeks on, people who had removal surgery were doing better.30PubMed Central. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial Stapled patients were about three times more likely to have hemorrhoids return and need more operations.31PubMed Central. Stapled versus conventional surgery for hemorrhoids Stage 4 tissue has been stretched outside for a long time, so lifting it may not hold.

HAL-RAR uses an ultrasound probe to find and tie the arteries feeding the hemorrhoids, then stitches loose tissue back up.32PubMed Central. Doppler-Guided Haemorrhoidal Artery Ligation and Rectoanal Repair (HAL-RAR): An Institutional Experience It tends to cause less pain and a faster return to work.33Journal of Coloproctology (Rio de Janeiro). Doppler-guided hemorrhoidal artery ligation with rectal mucopexy technique: initial evaluation of 42 cases But at stage 4, hemorrhoids were more than three times as likely to come back afterward.34PubMed Central. Doppler-Guided Haemorrhoidal Artery Ligation and Rectoanal Repair (HAL-RAR): An Institutional Experience Surgeons were also about seven times more likely to switch to removal surgery partway through for stage 4.35PubMed Central. Doppler-Guided Haemorrhoidal Artery Ligation and Rectoanal Repair (HAL-RAR): An Institutional Experience Some surgeons do offer it for stage 4, but it works best for stages 2 and 3.36Diseases of the Colon & Rectum. Doppler-Guided Hemorrhoidal Artery ligation and Rectoanal Repair (HAL-RAR) for the Treatment of Grade IV Hemorrhoids: Long-Term Results in 100 Consecutive Patients

That switch matters to you. If the surgeon finds the artery-tying procedure won’t deal with large outside tissue, they may convert to removal surgery in the same operation. Ask beforehand whether you’d agree to that and have it written on your consent form, because you may wake up having had a different operation, with the recovery that comes with it.

Laser hemorrhoidoplasty shrinks the tissue with heat from inside.37PubMed. Laser hemorrhoidoplasty for hemorrhoidal disease: a systematic review and meta-analysis Compared with open removal, it hurt less in the first day, shortened hospital stays, and caused fewer urination problems, with similar return rates in stages 2 to 4.38PubMed. Laser hemorrhoidoplasty for hemorrhoidal disease: a systematic review and meta-analysis For stage 4 it’s usually combined with artery tying or stitching.39PubMed Central. Best clinical practice recommendations for the management of symptomatic hemorrhoids via laser hemorrhoidoplasty: the LHP recommendations

Not every hospital offers laser or artery tying, and results depend on the surgeon’s experience. It’s worth asking what happens if you need a second procedure later.

Recovery and Managing Pain After Surgery

The first one to two weeks are usually the hardest. Pain is worst in the first days and tends to ease gradually, though bowel movements may stay uncomfortable longer. Light spotting, some discharge, and swelling are normal while the wounds heal. Plan to rest, avoid heavy lifting, and keep pain medicine on a regular schedule rather than waiting until the pain is bad.

Combining several pain treatments works better than relying on one.40PubMed Central. A Comprehensive Evidence Summary for Pain Assessment and Management After Hemorrhoidal Surgery to Inform Clinical Practice Guidelines Anti-inflammatory painkillers and numbing creams cut pain and the need for opioids.41Surgical Practice. Evidence‐Based Strategies for Post‐Hemorrhoidectomy Pain Management: A Systematic Review Laxatives, the antibiotic metronidazole, and plant-based flavonoid pills taken after surgery reduced pain.42PubMed Central. Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review Creams that relax the anal muscle, like diltiazem or nitroglycerin, can ease pain and help healing.43PubMed Central. A Comprehensive Evidence Summary for Pain Assessment and Management After Hemorrhoidal Surgery to Inform Clinical Practice Guidelines Early warm sitz baths and cold packs help, especially alongside medicine.44Surgical Practice. Evidence‐Based Strategies for Post‐Hemorrhoidectomy Pain Management: A Systematic Review

A sitz bath means sitting in a few inches of warm water that covers the anal area, in a clean bathtub or a small basin that fits over the toilet. Soaking for about ten to fifteen minutes relaxes the anal muscle, which eases spasm and soothes the wounds. Pat the area dry gently afterward rather than rubbing, since friction can irritate healing tissue.

The first bowel movement is often the most dreaded moment. Taking stool softeners from day one keeps it soft. Take pain medicine beforehand and soak in a warm bath afterward, and don’t strain or linger on the toilet with your phone. Some bleeding with early bowel movements is common, but heavy bleeding needs a call.

Some people can’t empty their bladder in the hours after surgery.45PubMed Central. Predictors of postoperative urinary retention after semiclosed hemorrhoidectomy It’s more likely in men, older people, those with higher body weight, and when four or more clusters are removed.46PubMed Central. Predictors of postoperative urinary retention after semiclosed hemorrhoidectomy Using opioid painkillers after surgery was linked to roughly double the risk.47PubMed Central. Predictors of postoperative urinary retention after semiclosed hemorrhoidectomy Tell staff right away if you can’t pee; a catheter relieves it quickly.

Call your surgeon for fever, pus, or rapidly worsening swelling, for bleeding that doesn’t stop or passes large clots, or if you can’t pee for many hours.

Living Well and Preventing a Return

People with hemorrhoids tend to report poorer quality of life than people without them.48PubMed Central. Quality of life in patients with hemorrhoidal disease How often symptoms occurred predicted that, while the grade and type of treatment did not.49PubMed Central. Quality of life in patients with hemorrhoidal disease So treatment aims at your symptoms, and reducing flare-ups is what improves daily life. Two people with the same grade can have very different days, because one may flare weekly while another has symptoms rarely.

After treatment, aim for a high-fiber diet and enough water so stools stay soft.50PubMed Central. Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study Go when you feel the urge and limit time on the toilet. Avoid heavy straining and long sitting where you can. Return to your doctor if bleeding or a bulge comes back.