If you read one guide on this site before your appointment, read this one. Almost every decision about treatment follows from the grade, and knowing what the number means makes the rest of the conversation much shorter.
The system measures one thing: how far an internal hemorrhoid has moved from where it started. Grade one has not come down at all. Grade two comes down and returns by itself. Grade three comes down and has to be pushed back by hand. Grade four stays down whatever you do.
That is the entire definition, and it is deliberately simple because it has to be established in a couple of minutes with an anoscope. It says nothing about size, nothing at all about how much the thing bleeds, and nothing about how much it hurts you.
Which is worth knowing in advance, because people often arrive expecting the grade to reflect how bad their symptoms feel. Internal hemorrhoids covers the condition itself, prolapse covers the reducibility check that separates three from four, and the examination covers how it is done.
Montreal grading guide
Grade by grade
What each grade opens up in Montreal
Grade one
Has not come down. Often settles with fibre, fluid and less straining, and frequently needs no procedure at all.
Grade two
Comes down and goes back by itself. This is the grade banding is most often described as well suited to.
Grade three
Has to be pushed back. Office procedures still apply, and this is where the surgical conversation starts appearing.
Grade four
Stays down. Nothing left for a band to pull back, so this is a surgical question from the outset.
A common misreading
The grade is not how bad it feels
People with a grade one can be thoroughly miserable, bleeding regularly and quietly dreading the bathroom. People with a grade three sometimes shrug the whole thing off. The grade measures position rather than suffering, and the two come apart far more often than you would expect them to.
What that means practically is that a low grade does not mean you have been overreacting, and a high grade does not mean you have been negligent about it. It means a particular set of options applies to you, which is a narrower and considerably more useful statement.
It also means that your symptoms still get taken entirely on their own terms. Bleeding gets assessed regardless of grade, conservative care is offered on symptoms rather than on the number, and red flags override the grade completely regardless of it.
PositionWhat it measures
Grades I to IIIOffice procedures
NoReflects symptoms
Where it leads
What your Montreal grade decides next
The condition behind the grading, the procedures each grade allows, and where surgery takes over.
What people ask after being given a number they were not expecting.
By examination with an anoscope, and by whether a prolapse returns on its own, needs pushing back, or stays down. It takes a couple of minutes and it cannot be done from a description.
No, and this trips people up. The grade measures how far the hemorrhoid has moved, not how much it bleeds or hurts. Grade one patients are often more miserable than grade three ones.
A mild grade two sometimes moves back toward one with more fibre, more fluid and less straining. Anything that already has to be pushed back is unlikely to reverse without something being done.
Because it no longer reduces, so there is nothing left for a band to pull back into position. At that point removing the tissue is the option that addresses what is actually there.
Indirectly. It decides which procedures apply, and the column count decided alongside it sets how many sessions a course runs to, which is the largest variable in your total.
Then you should be told that rather than handed a confident number, along with what each route would involve for you. A borderline case presented as obvious is the thing to be wary of.
The grades
One number, most of the decisions
It measures position
How far the hemorrhoid has moved, and nothing else. Not size, not bleeding, not how much it hurts.
One check settles it
Goes back by itself, needs pushing, or stays down. Those three answers are grades two, three and four.
Grade one often needs nothing
Fibre, fluid and less straining frequently settle it, and a procedure would be treating what was going away.
Borderline gets said
If the grade is genuinely close to a boundary, you should hear that rather than be given a confident answer.
