If you’re dealing with rectal bleeding, itching, or discomfort, you may be surprised to learn that “hemorrhoids” isn’t a single condition — it’s actually two distinct types, and knowing which one you have matters for both understanding your symptoms and choosing the right treatment. Here’s what sets internal and external hemorrhoids apart.
What Are Hemorrhoids?
Hemorrhoids are swollen blood vessels in and around the anus and rectum. They’re extremely common — roughly half of adults will experience symptomatic hemorrhoids at some point in their lives, with higher rates in people over 45 and those with chronic constipation or obesity. Hemorrhoids fall into two categories based on where they form: internal and external.
Internal Hemorrhoids
Internal hemorrhoids develop inside the rectum, above a boundary called the dentate line. Because this area has fewer pain-sensing nerves, internal hemorrhoids are typically painless — which is part of why they can go unnoticed until bleeding starts.
Common symptoms of internal hemorrhoids include:
- Painless bright red bleeding, often noticed on toilet paper or in the toilet bowl
- A feeling of pressure or fullness in the rectum
- Protrusion (prolapse) of the hemorrhoid during a bowel movement, which may retract on its own or need to be pushed back in
- Mucus discharge
Internal hemorrhoids are staged using a grading system based on how much they prolapse: Grade 1 hemorrhoids don’t prolapse at all, Grade 2 prolapse but reduce on their own, Grade 3 prolapse and require manual reduction, and Grade 4 are permanently prolapsed and can’t be pushed back in. Because internal hemorrhoids aren’t visible from the outside, diagnosis usually requires a digital rectal exam or imaging rather than a simple visual check.
External Hemorrhoids
External hemorrhoids form under the skin around the outside of the anus, in an area with many more pain-sensing nerves. This is why external hemorrhoids tend to be more painful and noticeable than internal ones.
Common symptoms of external hemorrhoids include:
- Itching or irritation around the anus
- Pain, especially when sitting
- Swelling around the anus
- Bleeding, though less commonly than with internal hemorrhoids
External hemorrhoids can also become thrombosed, meaning a blood clot forms inside them. A thrombosed external hemorrhoid often feels like a firm, tender lump and can appear bluish or purple — and it tends to be significantly more painful than a standard external hemorrhoid.
Key Differences at a Glance
- Location: Internal hemorrhoids form inside the rectum; external hemorrhoids form under the skin outside the anus.
- Pain: Internal hemorrhoids are usually painless; external hemorrhoids are often painful, especially if thrombosed.
- Bleeding: Internal hemorrhoids are the more common cause of visible rectal bleeding.
- Visibility: External hemorrhoids can often be seen or felt; internal hemorrhoids typically require an exam to diagnose.
When Should You See a Doctor?
Occasional mild hemorrhoid symptoms often improve with simple measures like increased fiber intake, more water, and avoiding straining during bowel movements. However, you should schedule an evaluation if you experience persistent or worsening bleeding, pain that doesn’t improve, a hemorrhoid that won’t reduce, or if symptoms are affecting your daily life. Rectal bleeding should always be evaluated by a medical professional to rule out other causes.
Treatment Differs by Type
Because internal and external hemorrhoids behave differently, treatment approaches differ too. External hemorrhoids often respond to conservative measures like warm sitz baths, topical treatments, and dietary changes, with surgical options reserved for severe or thrombosed cases. Internal hemorrhoids that don’t respond to conservative treatment have historically been treated with rubber band ligation, sclerotherapy, or surgery — but a minimally invasive, non-surgical option called hemorrhoid artery embolization (HAE) is now available for many patients with bleeding internal hemorrhoids, offering relief without cutting, banding, or instrumentation through the anus.
Curious how HAE stacks up against other treatment options? Read our companion post, HAE vs. Other Hemorrhoid Treatment Options.
If you’re dealing with symptomatic internal hemorrhoids in the Kansas City area, MIVA Medical’s board-certified interventional radiologists can help determine whether HAE is right for you. Take our HAE quiz or book a consultation to get started.