Grade 4 piles are haemorrhoids that stay outside the anus all the time and cannot be pushed back in. At that stage no cream, tablet or diet can put the tissue back where it belongs, and the choice is between operations — usually stapler haemorrhoidopexy (MIPH) or a haemorrhoidectomy. This article explains what Grade 4 means, why medicines stop working, and walks through a real, de-identified case treated at Sharvari Hospital, Pune.
Medically reviewed by Dr. Kundan Kharde, MS, FMAS — Founder & Director, Lead Proctology Surgeon, Sharvari Hospital, Pune. 19+ years, 6,000+ surgeries. View profile.
What “Grade 4” actually means
Internal piles are graded by how far they prolapse — how far the cushions of tissue lining the anal canal have slipped down:
- Grade 1 — bleed, but never come out.
- Grade 2 — come out on straining and go back on their own.
- Grade 3 — come out on straining and have to be pushed back with a finger.
- Grade 4 — stay out permanently and cannot be pushed back.
The grades are a timeline as much as a scale: almost every Grade 4 patient we see was Grade 2 a few years earlier. At Grade 4 the lump is simply there — a constant swelling at the anus, mucus, soiling, itching and a dull fullness that never quite goes. Bleeding tends to be intermittent rather than daily, which is one reason people keep postponing the visit. The full grade-by-grade picture is on grades of piles 1–4.
Why creams, tablets and banding stop working
Creams, sitz baths, fibre and stool softeners calm inflammation and make stool easier to pass. That reduces bleeding and pain, which is why they seem to work — for a while. What they cannot do is lift tissue. Grade 3–4 piles are a structural problem: the support that held the cushions inside the anal canal has given way, and soothing the surface will not re-suspend a cushion that has dropped below where it belongs. The relief from a cream is real, and it is also the reason many people lose another year.
Office procedures have the same ceiling. Rubber band ligation, sclerotherapy and infrared coagulation are effective for Grade 1–2 piles and selected small Grade 3 cases. Used on Grade 4 disease they under-treat the problem, and the patient comes back a year later saying “I had a procedure and it came back.” It did not come back; it was never adequately treated. The options that do work are compared on the Grade 3 & 4 piles treatment page.
A real case: ten years of “it goes back in”
A man in his fifties came to Sharvari Hospital with a history he had carried for about ten years: a swelling that came out of the anal region, and bleeding per rectum that came and went. For the first few years the swelling went back on its own. Then he had to push it in. By the time he came to us it stayed out all the time.
On examination the haemorrhoidal cushions were prolapsed all the way round the anal canal — a circumferential prolapse — and could not be reduced. That is Grade 4. The grooves between the individual cushions were still visible, which is how prolapsed piles are told apart from a full-thickness rectal prolapse, which comes out as concentric rings and needs an entirely different operation.
He was treated with stapler haemorrhoidopexy (MIPH) and discharged the next day. The pre-operative, intra-operative and immediate post-operative photographs — showing the anal verge restored on the table with no external wound — are on the case page, with the explicit images behind a tap-to-reveal: Grade 4 prolapsed piles treated with stapler (MIPH) — case study. The case is published with the patient’s written consent and every identifying detail removed.
Stapler vs laser vs haemorrhoidectomy for Grade 4
Three operations are realistic for Grade 4 piles. The choice is made from the anatomy at examination — how much has prolapsed, whether it is circumferential, how large the external component is, whether there is thrombosis, and what has been done before.
Stapler haemorrhoidopexy (MIPH / PPH)
A circular stapler removes a ring of redundant lower-rectal mucosa above the piles and staples the edges together. That lifts the prolapsed cushions back inside the canal and interrupts the vessels feeding them, so they shrink. Nothing is cut at the anal verge, so there is no external wound.
The trade-off, stated in one sentence: stapler haemorrhoidopexy causes less post-operative pain than open haemorrhoidectomy but has a higher rate of prolapse recurrence than haemorrhoidectomy, so it is chosen only when the anatomy suits it. The anatomy that suits it is a circumferential, mainly internal prolapse that reduces under anaesthesia without a large fixed external component — which is exactly what the case above had. Rare but serious stapler-specific complications exist and are part of the consent discussion.
Laser haemorrhoidoplasty (LHP)
A laser fibre shrinks the haemorrhoidal tissue from inside. It is the least painful option and suits selected Grade 2–3 piles, but laser alone does not lift a prolapse. For some Grade 3 and selected Grade 4 cases it is combined with a mucopexy (a suture lift); for a circumferential Grade 4 prolapse, laser alone is not adequate, and we say so rather than sell it. See laser piles vs open surgery.
Haemorrhoidectomy (open, closed or energy-device)
The piles are excised. It remains the reference operation for Grade 4 disease because it has the lowest long-term recurrence of any technique, and it is the most painful in the first week because the wounds sit at the anal verge. Energy devices such as LigaSure reduce bleeding and some of that pain. For Grade 4 piles with a large external component, thrombosis, or disease that has come back after a previous procedure, this is usually the right answer.
Questions to ask before Grade 4 piles surgery
- What grade am I, and is it circumferential or segmental? The answer determines everything else.
- Is this piles or rectal prolapse? The two look similar from outside and need different operations.
- Why this operation for my anatomy — and what is the recurrence trade-off? If you are offered a stapler, the surgeon should volunteer that it has higher prolapse recurrence than haemorrhoidectomy. If you are offered laser alone for Grade 4, ask what will lift the prolapse.
- What will the first week be like, and when is the first review? Get the stool-softening plan and the review date before admission.
- What is the written estimate, and what does insurance cover? See piles surgery cost in Pune.
Recovery, in general terms
After stapler haemorrhoidopexy the guidance is the same for every patient: keep the stool soft so the first motions do not strain the staple line, expect some urgency or fullness as the rectum settles, avoid heavy lifting early on, and return to desk work when comfortable — usually sooner than after open surgery and later than after a laser procedure. Timelines differ from person to person, and no number is promised. The week-by-week pattern is set out in recovery after piles surgery — day-by-day timeline.
If your piles stay outside
Piles that no longer go back in will not respond to another cream. An examination at Sharvari Hospital, Pimple Nilakh, tells you your grade, which operation your anatomy suits, and a written estimate — in one visit. Call +91 951 951 1928, book online, or start with the piles treatment in Pune guide. For patients coming from Wakad, Hinjewadi, Baner or PCMC, the hospital is 10–25 minutes away.
This article is for patient education and does not replace an examination. Every case is different; the operation is decided at consultation, not from a photograph.
