Prolapse means an internal hemorrhoid has come down past where it belongs. The question that matters is not how far, but whether it still goes back, because that single answer sets the grade and the options with it.
A hemorrhoid that comes down and then returns by itself is a grade two. One that comes down and has to be pushed back by hand is a grade three. One that stays down whatever you do is a grade four. That is the whole of the distinction, and it is the one that actually matters here.
Nobody can answer it from a description over the phone, and most people genuinely do not know which of the three applies to them. It takes an examination, which is why reducibility is checked rather than asked about at the first visit here.
Grades two and three that have not settled with conservative care are what office procedures address, banding most commonly of all. Grade four has nothing left to pull back into place, which moves it to removal instead.
Montreal examination
The route
From prolapse to your Montreal decision
What you have noticed
Whether something comes down, when it does it, and whether it goes back by itself or needs help.
Reducibility checked
The examination establishes which of grades two, three and four applies, rather than taking your estimate for it.
Columns counted
An anoscopy also shows how many columns are involved, which is what sets the number of sessions.
Office or theatre
Grades two and three go to office procedures. Grade four is discussed as a surgical question from the start.
Where surgery starts
When an operation is the right answer
Surgery here is not what happens when office treatment has failed. For a prolapse that no longer reduces, and for large external disease sitting alongside it, an operation is the correct first choice rather than a fallback, because there is simply nothing left that a band could usefully pull back into place.
Saying that plainly is more useful to you than offering a course of banding that was never going to hold. The honest version is that a grade four treated as though it were a grade two wastes your time and your money, and leaves the prolapse exactly where it was.
There is also more than one surgical route to consider, and they are not interchangeable. Stapled hemorrhoidopexy and THD are both alternatives for internal disease, and banding against surgery compares the trade-offs on each side so the choice is made with both in view.
Grade twoGoes back by itself
Grade threeNeeds pushing back
Grade fourStays down
Related
What sits alongside prolapse in Montreal
The grading behind it, and the procedures either side of the line where surgery takes over.
What people ask when something is coming down and they are trying to work out how serious that is.
By whether it goes back. If it returns on its own that is grade two; if you have to push it back, grade three; if it stays down, grade four. The examination confirms which.
People do, for years. It is not dangerous in itself, but it tends not to stay a grade three, and the options narrow as it progresses. Having it graded is the useful step.
For grades two and three it often does, by removing the tissue that is coming down. For grade four it does not, because there is nothing left to pull back into position.
No. For prolapse that no longer reduces it is the correct first choice, and treating it as a last resort usually means a course of banding that was never going to hold.
Longer than after an office procedure, which is the real trade-off rather than the risk. The comparison guide sets out what each side involves so the choice is made with both in view.
A mild grade two sometimes improves with more fibre, more fluid and less straining. Anything that has to be pushed back is unlikely to reverse without something being done.
Prolapse
Why reducibility is the whole question
Three grades, one test
Goes back by itself, needs pushing, or stays down. That is grades two, three and four settled in one check.
Checked, not asked
Most people do not know which applies to them, and an estimate is not something a treatment plan can rest on.
Surgery is not failure
For a prolapse that no longer reduces, an operation is the right first answer rather than the last one.
It tends to progress
A grade three left alone does not usually stay a grade three, and the options narrow as it moves.
One check settles whether this is a banding conversation or a surgical one. Tell us whether it goes back on its own, and we will confirm it at the visit.
