A grading scale is used to classify hemorrhoids. Grade I hemorrhoids become congested during defecation but do not prolapse through the anal canal. Grade II hemorrhoids protrude during straining, but spontaneously reduce on relaxation. Grade III hemorrhoids require manual reduction, which is usually easily accomplished. Grade IV hemorrhoids are irreducible protrusions and are sometimes confused with a true rectal prolapse. If grade II or III hemorrhoids do not reduce, edema rapidly occurs because the anal sphincter acts as a tourniquet. Swelling and pain prevent reduction, and an acute prolapse is said to have occurred. Grade IV hemorrhoids, which are chronically prolapsing, are often associated with a lax anal sphincter that is unable to retain the hemorrhoids in a reduced position.

Hemorrhoidectomy is generally performed for large, mixed, external and internal hemorrhoids (grades II through IV) that require surgical treatment. Alternative treatment methods (rubber band ligation, stapling, or even cryotherapy or laser treatment) may be appropriate for internal hemorrhoids and may be especially useful for grade I and II hemorrhoids that are associated with bleeding. These modalities are not applicable for large, mixed hemorrhoids, however.

Generally, sigmoidoscopy is performed before hemorrhoidectomy if it has not been performed in an office setting. Although the procedure may be performed using local anesthesia, it is more commonly performed with administration of general, spinal, or caudal anesthesia. In this chapter, classic hemorrhoidectomy and rubber band ligation are described. The references at the end describe alternative methods for the treatment of internal hemorrhoids as well as the specific technique for administering local anesthesia before minor rectal surgery.