Background Rubber band ligation is one of the most worldwide used treatments of hemorrhoids because of its effectiveness and low complication rate. Hemorrhoidectomy is the procedure of choice for treatment of grade four hemorrhoids, which is a painful method for a relatively benign disease. There are a few studies available analyzing the effectiveness of RBL as an initial treatment for grade four symptomatic internal hemorrhoids. Objectives This study aimed to analyze the efficacy of the staging rubber band ligation in the treatment of grade four hemorrhoids and compare it to hemorrhoidectomy. Patients and Methods A prospective randomized clinical trial was performed on all patients diagnosed with grade four symptomatic internal hemorrhoids from August 2011 to March 2013. Sixty four patients with grade four hemorrhoids were divided into two groups and underwent hemorrhoidectomy (H group) and rubber band ligation (R group).These patients were compared for any complications and recurrence in a six month period. Results Pain existed in 100% of the H group and 67.7% of the R group in the first visit one week postoperation (P < 0.05). There was a statistically significant difference between the two groups regarding the days off work. Patients’ satisfaction and recurrence were similar in the both groups after a period of six months. Conclusions This study showed that staging rubber band ligation is effective for treating grade four hemorrhoids. Few complications and low recurrence rates were noted, which enable us to recommend this modality as the procedure of choice for the management of selected patients with grade four symptomatic hemorrhoids.