Grade 4 Hemorrhoids in Abu Dhabi: When Surgery Is Necessary

You’ve been told you have Grade IV hemorrhoids. Maybe you’ve tried other treatments like banding, creams, or dietary changes, and they haven’t worked. For patients earlier in their journey, our hemorrhoid treatment in Abu Dhabi guide explains all grade-based options. Grade IV hemorrhoids almost always require surgery because less invasive treatments simply don’t work for this stage.

other treatments — banding, creams, dietary changes, and they haven’t worked. Or perhaps your hemorrhoids are permanently prolapsed (hanging outside the anus and won’t go back in) and you’re finally seeking help after months or years of putting it off.

Here’s the reality: Grade IV hemorrhoids almost always require surgery. Not because surgeons want to do surgery, but because less invasive treatments (banding, laser, even THD) simply don’t work for Grade IV disease. The hemorrhoid tissue is too prolapsed, too large, and often includes both internal and external components.

Surgery — specifically hemorrhoidectomy (surgical removal) — is the only treatment that reliably works.

I’m Professor Dr. Antonio Privitera, a consultant colorectal surgeon with fellowship training at the Mayo Clinic and Royal College of Surgeons (UK), practicing across Abu Dhabi. I perform hemorrhoidectomy regularly, and I also perform all the less invasive options (banding, laser, THD). When I recommend surgery, it’s because it’s the right match for your anatomy, not because it’s the only thing I do.

This article explains:

• What Grade IV hemorrhoids are (and why they need surgery)
• What hemorrhoidectomy actually involves
• Honest recovery timeline (not sugarcoated)
• Pain management strategies When to consider surgery even for Grade III
• Why delaying surgery often makes things worse For assessment of

whether surgery is necessary for your hemorrhoids:

What Are Grade IV Hemorrhoids?

Hemorrhoids are graded I through IV based on prolapse (how much they come out of the anus):

• Grade I: Bleed but don’t prolapse
• Grade II: Prolapse during straining, go back in automatically
• Grade III: Prolapse during bowel movements, require manual reduction (you push them back in)
• Grade IV: Permanently prolapsed and cannot be reduced (pushed back in)

Grade IV hemorrhoids:

• Stay outside the anus all the time
• Cannot be pushed back inside Often include large external components
• May have skin tags, inflammation, and chronic irritation
• Cause significant symptoms: bleeding, mucus discharge, discomfort, difficulty cleaning, embarrassment

For more on hemorrhoid grading, see our comprehensive hemorrhoid treatment guide.

Why Grade IV Hemorrhoids Need Surgery

Here’s why less invasive treatments don’t work for Grade IV:

Rubber Band Ligation (Banding) – Won’t Work

• Banding treats internal hemorrhoids by cutting off blood supply
• Grade IV hemorrhoids are permanently prolapsed with large external components
• Banding can’t address the prolapsed tissue or external components
• Attempting banding on Grade IV sets you up for failure and frustration

Laser Hemorrhoidoplasty – Insufficient

• Laser shrinks internal hemorrhoid tissue from inside
• Grade IV hemorrhoids are too large and too prolapsed for laser alone to be effective
• Laser doesn’t address external components or skin tags
• You’ll waste AED 15,000-25,000 and still need surgery

THD Procedure in Abu Dhabi: Complete Guide to Transanal Hemorrhoidal Dearterialization – Limited Role

• THD can work for some Grade IV cases if the external component is minimal
• But most Grade IV hemorrhoids have significant external tissue that THD can’t address
• Success rate for THD in Grade IV is much lower than for Grade II-III

Hemorrhoidectomy – The Definitive Solution

• Surgically removes both internal and external hemorrhoid tissue
• Addresses all components: prolapsed internal hemorrhoids, external hemorrhoids, skin tags
• Provides permanent relief in most cases
• Highest success rate and lowest recurrence of any treatment

Bottom line: If you have Grade IV hemorrhoids, surgery is almost always necessary. Attempting less invasive treatments first usually delays the inevitable while you continue suffering symptoms.

When Surgery Is Also Considered for Grade III

Grade III hemorrhoids (prolapse and require manual reduction) are a gray zone:

Try Less Invasive First:

• Many Grade III hemorrhoids respond well to THD or laser
• If the external component is small, these are worth trying first

Consider Surgery If:

• THD or laser has failed
• Large external component is present
• You want the most definitive treatment with lowest recurrence
• Symptoms are severe and significantly impacting quality of life

Discuss options with your surgeon. Some patients with Grade III prefer to try THD first (knowing surgery is backup if needed). Others prefer to go straight to surgery for definitive treatment.

What Is Hemorrhoidectomy? The Procedure Explained

Hemorrhoidectomy is the surgical removal of hemorrhoid tissue. Here’s what happens:

Pre-Operative:

• You’ll have pre-operative assessment (blood tests, medical clearance)
• Stop blood thinners if you’re on them (with cardiologist approval)
• Bowel preparation is usually NOT required (unlike colonoscopy)
• You’ll be admitted day-of-surgery (typically day-case — home the same day, or overnight stay)

Anesthesia:

• Spinal anesthesia (numbs lower body, you’re awake but feel nothing)

OR

• General anesthesia (fully asleep) The Surgery (30-60 minutes):

Positioning: You’re positioned for access to the anal area

Excision: I identify each hemorrhoid complex (usually 3 main positions) and:

1. Carefully dissect and remove the hemorrhoid tissue

2. Ligate (tie off) the blood vessels feeding the hemorrhoid

3. Either leave the wound open to heal naturally (open hemorrhoidectomy / Milligan-Morgan) or stitch it closed (closed hemorrhoidectomy / Ferguson)

Technique variations:

• Traditional: Using scalpel and electrocautery
• LigaSure or Harmonic scalpel: Energy devices that seal vessels as they cut (less bleeding)
• Laser-assisted: Using laser for cutting (marketed as “less painful” but evidence is mixed)

Open vs Closed:

• Open (Milligan-Morgan): Wounds left open, heal naturally over 4-6 weeks. Less postoperative complications (abscess/infection) but longer healing.
• Closed (Ferguson): Wounds stitched closed, faster healing but slightly higher risk of complications.

Both techniques have similar long-term outcomes. I choose based on hemorrhoid characteristics and patient factors.

Recovery Room:

• You’ll wake up in recovery with pain medication on board
• Once stable and able to urinate, you go home (or to ward if overnight stay)
• Pain medication, stool softeners, and post-op instructions provided

Recovery Timeline: The Honest Truth

• Day 1-3: Most challenging days. Significant discomfort during bowel movements. Use prescribed pain relief and sitz baths.
• Day 4-7: Gradual improvement. Can start moving around more. Stool softeners are critical.
• Week 2: Most patients return to light desk work.
• Week 4-6: Full healing of the surgical site.

2. Hemorrhoidectomy Outcomes and Pain Management – Modern approaches to postoperative care. Simillis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. 2015;102(13):1603-18. PubMed

3. Recurrence Rates After Hemorrhoidectomy – Long-term follow-up studies. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. 2006;(4): CD005393. PubMed

Medical Review: Written and reviewed by Prof. Dr. Antonio Privitera, consultant colorectal surgeon, fellowship training at the Mayo Clinic and Royal College of Surgeons (UK), and European Board Certification in Colorectal Surgery.

Assessment for Grade IV Hemorrhoids: Is Surgery Necessary?

Proper examination determines hemorrhoid grade — then we discuss whether surgery is needed or if less invasive options might work.

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• Burjeel Day Surgery Centre, Deerfields
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• Burjeel Medical City (BMC — surgery only)

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If surgery is necessary, I’ll explain exactly what to expect — no sugarcoating, but also no unnecessary fear.

Professor Dr. Antonio Privitera

Fellowship-trained at Mayo Clinic (USA) and the Royal College of Surgeons (UK). Member of the Royal College of Surgeons of Edinburgh. Certified in General Surgery by the Italian Medical Council.

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