What is the Golligers classification? Unpacking the Goligher System for Hemorrhoids

September 21, 2025 •

4 min read

Though often misspelled as the Golligers classification, the correct name for this system is the Goligher classification. A medical classification system for hemorrhoidal disease is widely used by clinicians to assess the severity of internal hemorrhoids, primarily based on the degree of prolapse.

Quick Summary

The Goligher classification is a four-grade system for internal hemorrhoids, ranking severity based on the degree of anal mucosal prolapse, which helps guide treatment decisions. While widely used, its simplicity can limit its effectiveness compared to more comprehensive diagnostic methods that consider symptoms beyond just prolapse.

Key Points

Prolapse-Based Grading: The Goligher classification is a four-grade system that classifies the severity of internal hemorrhoids based solely on the degree to which they prolapse (protrude) from the anus.
Grade I to IV Progression: Grades range from no prolapse (Grade I) to spontaneous reduction after prolapse (Grade II), manual reduction needed (Grade III), and permanently prolapsed (Grade IV).
Long-Standing but Flawed: While widely used for its simplicity since its development in the 1970s, the system has significant limitations, including poor interobserver reliability.
Ignores Key Symptoms: A major drawback is its failure to account for other important symptoms like bleeding, pain, and itching, which can have a more significant impact on a patient's life.
Spurred New Systems: The recognized limitations of the Goligher system have prompted the development of more comprehensive classification systems, such as BPRST, that include a wider range of clinical features.
Still a Clinical Reference: Despite its flaws, the Goligher classification remains a common reference point in medical practice, though it is often supplemented by additional patient information for a complete diagnosis.

Understanding the Goligher Classification

The Goligher classification is a long-standing method developed in the 1970s for grading internal hemorrhoids based on the degree of prolapse, or descent, of the anal cushions. This system provides a standardized language for doctors to communicate the severity of hemorrhoidal disease. Its simplicity has made it a convenient tool for clinical practice and research for decades, though modern medicine recognizes several limitations. The classification is focused solely on the physical protrusion of the hemorrhoids and does not take into account other critical symptoms, such as bleeding, pain, or itching, which can significantly impact a patient's quality of life.

The Four Grades of Internal Hemorrhoids

The Goligher system categorizes internal hemorrhoids into four distinct grades based on their behavior during and after defecation. The grading is typically determined by a physical examination and patient history.

Grade I: In this initial stage, the hemorrhoids do not prolapse out of the anus. They remain internal but can cause symptoms such as painless bleeding during bowel movements. They are essentially swollen venous cushions, not an external protrusion.
Grade II: Prolapse occurs during defecation but reduces spontaneously. This means the hemorrhoid tissue pushes outside the anal canal while straining but retreats back inside on its own afterward.
Grade III: These hemorrhoids prolapse during defecation and require manual manipulation (a person's finger) to be pushed back inside the anal canal. This grade is often associated with more significant discomfort and potential for complications.
Grade IV: At this most advanced stage, the hemorrhoids are permanently prolapsed and cannot be manually reduced. They remain outside the anal canal at all times, making them susceptible to complications such as thrombosis (blood clots), strangulation, and skin irritation.

Limitations of the Goligher Classification

Despite its widespread use, the Goligher classification has several well-documented drawbacks that have spurred the development of alternative grading systems. Critiques often center on its oversimplification of a complex condition and its focus on only one symptom: prolapse.

Interobserver variability: Studies have shown a significant variation in how different healthcare providers grade the same patient using the Goligher system, especially for Grades II and III. This poor reliability can lead to inconsistent diagnoses and treatment plans.
Neglects other symptoms: The system does not account for the severity of other, often more distressing, symptoms like bleeding, pain, itching, or incontinence. A patient with a Grade I hemorrhoid and significant bleeding might have a worse quality of life than a patient with a Grade III hemorrhoid and minimal discomfort.
Inadequate for mixed hemorrhoids: The classification only addresses internal hemorrhoids and fails to adequately describe or grade mixed hemorrhoids (involving both internal and external components) or those with acute thrombosis.
Poor correlation with treatment outcomes: Recent research has indicated that the Goligher grade does not always correlate well with the outcome of surgical procedures, limiting its effectiveness as a tool for comparing treatment efficacy.

Comparison with Newer Classification Systems

To overcome the shortcomings of the Goligher classification, several new systems have been developed. These often incorporate a broader range of factors, including symptoms and patient-reported outcomes, to provide a more holistic assessment.


Feature	Goligher Classification	BPRST Classification (e.g.)
Primary Focus	Degree of prolapse	Multiple factors: Bleeding, Prolapse, Reduction, Skin Tags, Thrombosis
Symptom Consideration	Limited to prolapse	Comprehensive (includes bleeding, thrombosis)
Clinical Application	Simple and widely used for initial assessment	More detailed, better associated with specific treatments
Reliability	Prone to interobserver variability	Designed to be more objective and reliable
Grading	Four grades (I-IV) based on prolapse	Multi-factorial, staging based on comprehensive criteria
Limitations	Lacks detail, poor reproducibility, overlooks key symptoms	More complex, potentially hindering widespread adoption

Modern Clinical Application and Outlook

While the Goligher classification remains a foundational concept taught to medical students and is still widely referenced, its role in modern clinical practice is evolving. Clinicians often use it as a starting point but integrate additional information from patient-reported symptoms and other diagnostic findings to create a more complete picture of the disease. A comprehensive assessment, including factors like bleeding severity and the presence of thrombosis, is crucial for guiding effective and patient-centered treatment decisions. Research continues to explore more reliable and comprehensive classification systems that better reflect the patient's experience and guide more personalized care, though replacing the simple Goligher system entirely has proven challenging.

For more detailed information on current research and alternative classification systems, you can consult authoritative medical sources. Frontiers in Medicine provides a comprehensive review of hemorrhoidal classifications.

Conclusion

The Goligher classification, despite its limitations, has been the standard grading system for internal hemorrhoids for decades due to its simplicity. It offers a straightforward way to categorize the disease based on the degree of prolapse, guiding initial management decisions. However, its incomplete assessment of symptomatic severity and its inconsistent application underscore the need for a more comprehensive approach. As research advances, newer, multi-faceted classifications offer a more detailed and patient-centered view, though the Goligher system will likely remain a relevant part of the clinical conversation for its ease of use.

Frequently Asked Questions

The classification system was developed by Mr. John C. Goligher in the 1970s. While there have been minor adjustments over the years, his system for grading hemorrhoids remains a cornerstone in proctology.

The main distinction is how they reduce after prolapsing. Grade II hemorrhoids reduce spontaneously on their own, while grade III hemorrhoids require the patient to manually push them back inside.

No, the Goligher classification is designed specifically for internal hemorrhoids and is based on their degree of prolapse. It does not apply to external hemorrhoids or hemorrhoidal disease with a thrombosed external component.

Some criticisms include its high interobserver variability, its narrow focus on only prolapse and exclusion of other symptoms like bleeding and pain, and its poor correlation with patient-reported outcomes.

Physicians commonly use the classification as a guide to determine the most appropriate treatment option. For example, lower grades (I and II) might be managed with conservative or office-based treatments, while higher grades (III and IV) are more likely to require surgery.

Several alternative systems exist, with one example being the BPRST classification, which incorporates additional factors like Bleeding, Prolapse, Reduction, Skin Tags, and Thrombosis to provide a more comprehensive picture of hemorrhoidal disease.

While useful, its accuracy is limited due to focusing solely on prolapse and its high degree of interobserver variability. A reliable diagnosis often requires a broader assessment of a patient's full symptom profile.