Table Classification of Internal Hemorrhoids Grade Features I Prominent hemorrhoids No prolapse II Prolapse after a Valsalva maneuver Prolapse reduces spontaneously III Prolapse after a Valsalva maneuver Prolapse needs manual reduction IV Chronic prolapse Manual reduction of prolapse ineffective Adapted from the American Society of Colon and Rectal Surgeons' 2018 clinical practice guidelines for the management of hemorrhoids.