Does Grade 4 Hemorrhoids Need Surgery? Detailed analysis.


It is not uncommon for us to receive questions like do grade 4 hemorrhoids need surgery or not. The simple answer is yes. 

Grade 4 hemorrhoids, characterized by permanent prolapse through the anus, usually necessitate surgery since they are unlikely to resolve without procedural intervention.

As the most advanced stage, grade 4 hemorrhoids often continue worsening and causing symptoms if left untreated. Surgery is frequently needed to excise or reposition the severely enlarged, protruding hemorrhoidal tissue.

Grade 4 Hemorrhoids Need Surgery Or Not: Key Points To Understand

  • Grade 4 hemorrhoids usually necessitate surgery due to constant prolapse.
  • The protruding tissue progressively worsens without treatment.
  • Severe complications can arise if surgery is delayed.
  • Hemorrhoidectomy and hemorrhoidopexy are standard surgical options.
  • Less invasive methods may be attempted but often fail.
A doctor showing a watch in front of hemorrhoids model.

Why Surgery Is Often Necessary For Grade 4 Hemorrhoids?

Chronic External Prolapse

The distinguishing feature of grade 4 hemorrhoids is constant prolapse that never retracts on its own.

The hemorrhoidal tissue remains prolapsed outside the anus at all times. Surgery is typically required to return the prolapsing tissue back inside.

Progressive Enlargement 

Without treatment, grade 4 hemorrhoids tend to progressively enlarge over time as the straining continues.

The prolapsing tissue becomes increasingly swollen. Surgery removes the diseased tissue before it expands more.

Weakened Rectal Muscles

In grade 4 hemorrhoids, the rectal muscles have typically become too weakened to effectively retain tissue inside the anal canal.

Surgery can reconstruct and tighten the rectal muscles.

Failure of Conservative Measures

Non-surgical treatments like diet changes, ointments, and warm baths cannot repair severely prolapsed hemorrhoids on their own.

They only provide temporary symptom relief.

Hemorrhoids written in front of an anatomical model.

Risk of Complications

Leaving grade 4 hemorrhoids untreated increases the risk of complications like strangulation, where prolapsing tissue becomes trapped and loses blood flow.

Surgery is performed to prevent this.

When Is Surgery Absolutely Necessary?

If grade 4 hemorrhoids become severely thrombosed or necrotic, surgery is urgently needed to remove the tissue before infection sets in.

Abscesses may also require immediate surgical drainage. Intractable bleeding not controlled with other measures necessitates surgery. 

What Are The Surgical Options?

The two main surgeries are:

  • Hemorrhoidectomy
    Excision of hemorrhoids
  • Hemorrhoidopexy
    Stapled repositioning of hemorrhoidal tissue

Both procedures allow prolapsed tissue to be reinserted back within the anal canal. Hemorrhoidectomy is more invasive but removes all diseased tissue. Hemorrhoidopexy is less invasive but may not address all enlarged hemorrhoids.

Considering Less Invasive Options First

While grade 4 hemorrhoids generally require surgery, some specialists may try office-based procedures like sclerotherapy injections or infrared coagulation first.

However, the protruding tissue has to be manually reinserted into the anus with each treatment since prolapse is constant.

This is not always possible if the hemorrhoids are too large, in which case surgery is definitively needed.

Final Note From Dr. Rajarshi Mitra

I hope this overview explains why grade 4 hemorrhoids commonly require surgical intervention for definitive treatment.

Surgery is often ultimately needed to remove or reposition severely prolapsed tissue and prevent deterioration.

Please let me know if you have any other questions!


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  • Anal Fissure
  • Anal Fistula
  • Gallbladder
  • Hemorrhoids
  • Inguinal Hernia
  • Pilonidal Sinus
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Based on 566 reviews
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