For advanced, prolapsed and recurrent piles — including cases already treated elsewhere
Grade 3 piles prolapse out of the anus and must be pushed back manually; Grade 4 piles stay permanently prolapsed and cannot be reduced. Both are advanced hemorrhoids that do not respond to creams, banding or dietary change alone. At Sharvari Hospital, Pimple Nilakh, Pune, they are treated surgically — with laser hemorrhoidoplasty plus mucopexy, stapled hemorrhoidopexy, or energy-device hemorrhoidectomy — selected by how much tissue has prolapsed.
Prolapsed piles that will not go back in are treated as urgent.
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Creams, sitz baths, fibre and stool softeners manage symptoms. They do not lift prolapsed tissue back inside. Rubber band ligation, sclerotherapy and infrared coagulation work well for Grade 1 and Grade 2 piles and for selected small-volume Grade 3 cases — but used on large, circumferential Grade 3 or on Grade 4 disease they under-treat the problem, which is one of the commonest reasons patients tell us "I had a procedure but it came back."
Grade 3 and Grade 4 piles are a structural problem: the cushions of tissue that line the anal canal have slipped down and lost their support. The fix has to be structural too.
Hemorrhoids are graded using the Goligher classification:
| Grade | What happens | Typical symptoms | What actually works |
|---|---|---|---|
| Grade 1 | No prolapse. Piles stay inside. | Painless bleeding | Diet, medication, sclerotherapy, IRC |
| Grade 2 | Prolapse on straining, goes back on its own | Bleeding, fullness | Banding, sclerotherapy, laser |
| Grade 3 | Prolapse on straining, must be pushed back by hand | Bleeding, mucus, discomfort, soiling | Banding in selected small-volume cases (higher recurrence than surgery); otherwise laser + mucopexy, stapled hemorrhoidopexy or hemorrhoidectomy |
| Grade 4 | Permanently prolapsed. Cannot be pushed back. | Constant lump, pain, discharge, soiling, risk of thrombosis | Hemorrhoidectomy (± energy device), stapler in selected cases, laser + pexy in selected cases |
Also urgent, regardless of grade:
If your piles are permanently out, severely painful, or the lump has turned dark, treat it as an emergency. Sharvari Hospital is open 24×7.
This is a Grade 4 circumferential prolapse in a man in his fifties who had lived with a swelling coming out and on-and-off bleeding for about ten years: the haemorrhoidal cushions sit permanently outside the anal verge and cannot be pushed back. Because the prolapse was circumferential and mainly internal cushion, it was treated with stapler haemorrhoidopexy (MIPH) rather than laser, and he went home the next day. The full case, including the intra-operative and immediate post-operative photographs, is on the Grade 4 piles stapler (MIPH) case study.
This distinction matters, and it gets missed.
| Feature | Grade 4 piles | Rectal prolapse |
|---|---|---|
| What protrudes | Separate cushions of hemorrhoidal tissue with grooves between them | Full thickness of the rectal wall |
| Pattern | Radial folds, distinct lumps | Concentric (circular) rings |
| Typical patient | Adults across age groups | More often older adults, and women with pelvic floor weakness |
| Treatment | Hemorrhoid surgery | Completely different operation — rectopexy |
Operating on a rectal prolapse as if it were piles does not work, and treating it as piles delays proper care. Where the picture is unclear, we examine and, if needed, image before deciding.
| Procedure | Best suited to | Hospital stay | Recovery to work | Trade-off |
|---|---|---|---|---|
| Laser hemorrhoidoplasty (LHP) | Grade 2–3; Grade 3–4 only in combination with mucopexy | Daycare / 1 day | ~3–7 days | Least pain; alone it shrinks tissue but does not lift a large prolapse |
| Laser + mucopexy / pexy | Grade 3, selected Grade 4 | 1 day | ~5–10 days | Adds the lift that laser alone lacks |
| Stapled hemorrhoidopexy (MIPH/PPH) | Circumferential Grade 3; selected Grade 4 where the prolapse is mainly internal cushion and reduces under anaesthesia, after counselling | 1–2 days | ~7–10 days | Less pain than open surgery, but higher recurrence of prolapse than hemorrhoidectomy; not suited to large external components; rare but serious stapler-related complications |
| Energy-device hemorrhoidectomy (LigaSure / harmonic) | Grade 3–4, large or circumferential disease | 1–2 days | ~2–3 weeks | Less pain and bleeding than conventional excision |
| Open / closed hemorrhoidectomy (Milligan-Morgan / Ferguson) | Grade 4, extensive, thrombosed or recurrent disease | 1–2 days | ~2–3 weeks | Reference standard with the lowest long-term recurrence; most postoperative pain |
| Emergency hemorrhoidectomy | Strangulated or severely thrombosed piles | 1–2 days | ~2–3 weeks | Done urgently to prevent tissue loss |
How we choose: grade and extent of prolapse → circumferential or segmental → size of the external component → thrombosis → previous procedures → your work and recovery constraints.
The honest trade-off: the least painful option is not always the most durable one. For genuine Grade 4 disease, a well-performed hemorrhoidectomy still has the lowest recurrence rate of any technique — and we will tell you when that is the right answer rather than sell you a laser that will not hold.
Laser piles vs open surgery compared · Laser piles surgery at Sharvari
Recurrence after piles treatment usually has an identifiable reason:
The grade was under-treated — banding or sclerotherapy used on large, circumferential Grade 3 or on Grade 4 disease
Only part of the disease was addressed — internal component treated, large external component left
Circumferential disease treated segmentally
The underlying driver was never fixed — chronic constipation, prolonged straining, long sitting hours, untreated fissure
Structural prolapse was never lifted — shrinking tissue without pexy in a Grade 3–4 patient
We reassess from the beginning, grade it properly, and choose a procedure sized to the actual disease.
Can piles be cured permanently?
Not every problem after a previous procedure is recurrence — sometimes the piles are gone and the trouble is the scar. Complications can follow any anorectal surgery, whatever the technique; what matters is recognising early that the recovery is off track and putting a corrective plan in place. Persistent pain, thin stools or a wound still open at six to eight weeks most often means scar narrowing of the anal canal (anal stenosis) or a non-healing wound, both of which can be corrected surgically — see how it was done in a de-identified case of anal stenosis after piles surgery elsewhere.
| Milestone | Laser / laser + pexy | Stapled hemorrhoidopexy | Hemorrhoidectomy |
|---|---|---|---|
| Hospital stay | Daycare–1 day | 1–2 days | 1–2 days |
| Desk work | ~3–7 days | ~7–10 days | ~2–3 weeks |
| Full activity | ~2 weeks | ~2–3 weeks | ~4 weeks |
| First bowel movement | Usually day 1–2, with laxative cover | Day 1–2 | Day 1–2, pain expected |
Every patient goes home with a stool-softening regimen, sitz bath instructions, pain control and a review schedule. Prolonged straining after surgery is the fastest route to recurrence — we take the aftercare as seriously as the operation.
Recovery after piles surgery — day-by-day timeline · What to eat after piles surgery
Advanced piles cost more than Grade 1–2 treatment because they require an operating theatre, anaesthesia, admission and, often, a larger procedure.
| Component | Indicative |
|---|---|
| Consultation & grading | As per current schedule |
| Laser / laser + pexy | Quoted after examination |
| Stapled hemorrhoidopexy | Quoted after examination — stapler device cost included in estimate |
| Hemorrhoidectomy (± energy device) | Quoted after examination |
Written estimate before admission. Cashless with 50+ insurers. Piles surgery is covered under most health insurance policies.
24×7 emergency — +91 951 951 1928.
📞 Call nowDr. Kundan Kharde — Founder & Director — Lead Proctology Surgeon. 19+ years, 6,000+ surgeries, 4.9★ across 140+ Google reviews on his practice profile.
→ Dr. Kharde on why laser alone is not enough for Grade 4 piles
Grade 4 piles are permanently prolapsed and require surgery. Hemorrhoidectomy, conventional or with an energy device such as LigaSure, remains the reference standard because it has the lowest long-term recurrence. Stapled hemorrhoidopexy or laser combined with mucopexy is used in selected cases depending on the extent of prolapse.
No. Medication, diet and sitz baths relieve symptoms but cannot reposition permanently prolapsed tissue. Rubber band ligation, sclerotherapy and infrared coagulation are effective in Grade 1 and Grade 2 hemorrhoids and in selected small-volume Grade 3 cases, not in Grade 4.
Laser hemorrhoidoplasty alone shrinks hemorrhoidal tissue but does not lift a large prolapse. For Grade 3 and selected Grade 4 cases it is combined with mucopexy; for extensive Grade 4 disease, hemorrhoidectomy is usually more durable.
Usually not on its own. Laser haemorrhoidoplasty shrinks haemorrhoidal tissue but does not lift a prolapse, so it suits selected Grade 2–3 piles. A circumferential Grade 4 prolapse that stays outside the anus usually needs stapler haemorrhoidopexy or a haemorrhoidectomy, and which of the two is decided at examination from the anatomy — the size of the external component, thrombosis and previous procedures.
Grade 3 piles prolapse on straining and must be pushed back manually. Grade 4 piles are permanently prolapsed and cannot be reduced.
The commonest reason is that the grade was under-treated — for example banding used on large, circumferential Grade 3 or on Grade 4 disease — or that a structural prolapse was shrunk but never lifted. Re-grading and a correctly sized procedure usually resolves it.
Hemorrhoidectomy is the most painful of the options, with significant discomfort in the first week, managed with medication, stool softeners and sitz baths. Stapled and laser-based procedures cause less pain but are not suitable for every Grade 4 patient.
Usually one to two days. Laser-based procedures in selected patients may be performed as daycare.
Approximately 3 to 7 days after a laser-based procedure, 7 to 10 days after stapled hemorrhoidopexy, and 2 to 3 weeks after hemorrhoidectomy.
Yes. Piles surgery is covered under most health insurance policies and Sharvari Hospital offers cashless treatment with over 50 insurers.
Yes, in most cases — but it is assessed on examination, not from the history alone. Persistent pain, thin stools or a wound that has not closed months after a piles procedure usually has a physical cause: scar narrowing of the anal canal (anal stenosis), a non-healing wound, or a fissure in the scar. Scar narrowing and non-healing wounds can be corrected surgically — by releasing the stricture and covering the raw area with healthy mucosa (mucoplasty), as in this de-identified case. Bring your previous discharge summary and operation notes; the plan is made from what is found on examination.
Prolapsed piles appear as separate cushions of tissue with grooves between them, while rectal prolapse protrudes as concentric circular rings of full-thickness rectal wall. The two require completely different operations, so examination by a proctologist before treatment is essential.
Laser is excellent for the right patient — usually Grade 2 and Grade 3. In advanced Grade 4 or prolapsed piles, other techniques often give better, longer-lasting results. Dr. Kundan Kharde explains where the line is and why.
This video covers laser piles surgery in general. For Grade 4 and prolapsed piles specifically, your options are set out on this page and confirmed at consultation.
Verified Google reviews from Sharvari Hospital patients, Pimple Nilakh, Pune.
“Excellent experience for my laser surgery. Minimal pain, quick discharge and detailed follow-up instructions. The doctor answered all my questions without rushing.”
Sumeeran Kesarkar
Pune (Pimple Nilakh / Wakad / PCMC)
Minimal pain · Quick discharge“Highly recommend Sharvari Hospital for laser and laparoscopic surgeries. Good follow-up and very approachable team. Recovery matched what was discussed during counselling.”
Chandan M Shahu
Pune (Pimple Nilakh / Wakad / PCMC)
Recovery matched plan“Very professional and caring team. The doctor explained the procedure clearly and my recovery was smooth and comfortable. I appreciated the calm environment and the way staff coordinated admission and discharge through every step.”
Ameya
Pune (Pimple Nilakh / Wakad / PCMC)
Smooth recovery“From admission to discharge, everything was well organized. Nurses and staff were very supportive throughout my stay. Instructions after surgery were clear and follow-up was easy to arrange.”
Omkar Salanki
Pune (Pimple Nilakh / Wakad / PCMC)
Well-organised stay“The hospital ambience is clean and calm. The doctor listens patiently and gives confidence to the patient and family. I felt informed before consenting for the procedure.”
Suryanarayana Kotnak
Pune (Pimple Nilakh / Wakad / PCMC)
Clear counselling“I came here on a friend's recommendation and was very happy with the treatment and the prompt response of staff. Billing and documentation were explained simply.”
Robin John
Pune (Pimple Nilakh / Wakad / PCMC)
Prompt responseWakad · Hinjewadi · Baner · Aundh · Balewadi · Ravet · Tathawade · Pimple Saudagar · Pimple Nilakh · Pimpri-Chinchwad
SR. NO. 19(P), behind Gulmohor Park, Vishal Nagar, Pimple Nilakh, Pune 411027 · Open 24 hours · +91 951 951 1928
Prolapsed piles do not improve on their own — an examination tells you your grade, your options and a written estimate, in one visit.