Types of Piles: Internal, External, and Grade I to IV Explained
Reviewed by Dr. Gaurang Ramesh
MBBS, MS, FSGE, Surgical Gastroenterologist and Integrative & Functional Medicine Practitioner
Arka Anugraha Hospital, JP Nagar, Bangalore
Piles are not a single, uniform condition. There are two broad types, internal and external, and internal piles are further staged into four grades based on severity. Knowing which type and grade you have is often the first real step toward understanding your treatment options, because a Grade I internal pile and a Grade IV prolapsed pile are managed very differently.
This page focuses only on classifying piles by type and stage. For a full explanation of what piles are and why they happen, see our complete piles guide, and for symptoms and diagnosis, see our dedicated page on that topic.
Internal Piles: What They Are
Internal piles form inside the rectum, above the area where nerve endings that sense pain are concentrated. Because of this location, according to Mayo Clinic, internal piles are usually painless and the most common sign is bleeding, typically bright red blood seen on toilet paper or in the toilet bowl after a bowel movement. In more advanced cases, internal piles can prolapse, meaning they slip down through the anus and become visible or felt as a soft lump.
External Piles: What They Are
External piles develop under the skin around the anus, in an area rich in pain-sensing nerves. This means external piles are more likely to cause discomfort, itching, and swelling than internal piles. If a blood clot forms inside an external pile, it becomes a thrombosed external hemorrhoid, which Cleveland Clinic describes as a hard, painful, dark blue or purple lump that can develop suddenly and is often the most painful form of piles.
Grades of Internal Piles (Grade I to IV, Goligher Classification)
Internal piles are staged using the Goligher grading system, a widely used clinical classification that goes from Grade I to Grade IV based on the degree of prolapse:
Grade I (first degree piles): The piles stay inside the anal canal and do not prolapse. Bleeding may be the only symptom, and these are often described as acute piles that respond well to dietary and lifestyle changes.
Grade II: The piles prolapse, or bulge out, during straining or a bowel movement, but return inside on their own afterward.
Grade III: The piles prolapse during straining and need to be pushed back in manually.
Grade IV (fourth degree piles): The piles are permanently prolapsed and cannot be pushed back inside. These are considered chronic piles and typically need more active treatment.
Mixed piles, where a patient has both significant internal and external components, and non-bleeding piles that cause discomfort without visible blood, are also seen regularly in clinical practice and are assessed using the same overall framework.
Prolapsed and Thrombosed Piles
As a general pattern, Grade I and many Grade II piles are managed with dietary changes, topical treatments, and sometimes minor in-clinic procedures. Grade III and Grade IV piles, along with thrombosed or persistently prolapsed piles, more often require a procedure or surgery, since they are less likely to resolve with lifestyle changes alone. That said, grading is only one part of the picture; your doctor will also consider your symptoms, overall health, and how much the condition is affecting your daily life. Our full guide to piles treatment options explains each pathway in more detail, and our piles surgery guide covers what to expect if a procedure is recommended.
How Arka Anugraha Diagnoses Your Piles Type
At Arka Anugraha Hospital, determining your exact type and grade starts with a detailed history and a physical examination, sometimes supported by a proctoscopy or anoscopy to view the internal piles directly. This step matters because self-diagnosing from symptoms alone can be unreliable, particularly since piles can resemble other conditions like anal fissures. Our page on piles symptoms and diagnosis explains this evaluation process in full, including when further tests like a colonoscopy may be recommended.
Frequently Asked Questions (FAQ)
Internal piles form inside the rectum and are usually painless but can bleed, while external piles form under the skin around the anus and are more likely to cause pain and itching, according to Mayo Clinic.
Grade 4 piles are internal piles that are permanently prolapsed outside the anus and cannot be pushed back in. This is the most advanced stage on the Goligher grading scale and usually needs active treatment.
Grade 1 piles often improve significantly with a high-fiber diet, adequate hydration, and reduced straining, though they should still be evaluated by a doctor to confirm the diagnosis.
A thrombosed external hemorrhoid is very painful but is not usually a medical emergency. It is still worth prompt evaluation, since early treatment can meaningfully reduce discomfort.
Grading is determined through a physical examination and, when needed, a proctoscopy, which allows the doctor to directly view internal piles and assess the degree of prolapse.
This content is for informational purposes only and does not replace professional medical advice. Always consult a qualified doctor.
Explore Arka Recipes
Discover recipes that blend taste with health, crafted by our experts for your well-being.
Arka Diagnostics
Discover groundbreaking diagnostic services exclusive to India, now available at Arka Health, Bangalore
Social Share
Book An Appointment
Related Articles
Not Sure Which Type You Have?
Self-assessing piles from symptoms alone can be misleading. Request our free Piles Symptom Checklist to better understand the signs of internal and external haemorrhoids before your consultation. Our care coordinator will also help you arrange an evaluation with our colorectal team at a convenient time and answer any questions about the next steps.
Request Your Free Symptom Checklist