Internal vs external hemorrhoids: how to tell the difference

Internal hemorrhoids form inside the back passage. You usually cannot see or feel them, and the main sign is painless, bright red blood after a bowel movement. External hemorrhoids form under the skin around the opening, so you can feel them as a lump, and they are more likely to itch or hurt (NIDDK).

Hemorrhoids are also spelled haemorrhoids, and in the UK, South Africa and Australia they are often called piles. They are very common: about half of adults over 50 have them (NIDDK). This guide explains each type, the four grades of internal hemorrhoids, what they look and feel like, and how to tell them apart from a skin tag or a small tear.

What are hemorrhoids?

Everyone is born with hemorrhoids. They are blood vessels in the lining of the anus (the opening where stool comes out) and the lower rectum (the last part of the bowel). They only cause trouble when they swell and get bigger (Cleveland Clinic).

Things that make swelling more likely include constipation, pushing hard on the toilet, sitting there for a long time, heavy lifting, pregnancy, getting older and being overweight (NHS).

Types of hemorrhoids

Doctors name hemorrhoids by where they form. There are two main types, plus two things that can happen to them:

• Internal hemorrhoids form in the lining inside the anus and lower rectum.
• External hemorrhoids form under the skin around the opening.
• A prolapsed hemorrhoid is an internal one that has slipped out through the opening.
• A thrombosed hemorrhoid is one with a blood clot inside. This usually happens in an external hemorrhoid.

(NIDDK; Cleveland Clinic)

You can have more than one type at once. When someone has both internal and external hemorrhoids that keep causing trouble, doctors can treat them together (ASCRS guideline 2024).

Internal vs external hemorrhoids at a glance

Sources: NIDDK, Cleveland Clinic, ASCRS guideline 2024.

Internal hemorrhoids

The classic sign of an internal hemorrhoid is painless bleeding when you open your bowels. Some people also notice tissue that comes out now and then (ASCRS guideline 2024). The blood is bright red and you see it on the toilet paper, in the bowl or streaked on the stool (NIDDK).

Many people with internal hemorrhoids do not know they have them, because they sit inside where you cannot see or feel them (Cleveland Clinic). You might also notice mucus on the paper or in your underwear, or a feeling that you still need to go after you have been (NHS).

Hemorrhoid grades 1, 2, 3 and 4

Doctors grade internal hemorrhoids by how far they come out. The grade tells you a lot about what is likely to help.

Sources: grades from Cleveland Clinic; treatment from the ASCRS guideline 2024 and NHS.

For every grade, the first step is the same: more fibre and fluid, and better toilet habits such as not straining and not sitting there for long. US colorectal surgeons call these the main first treatment (ASCRS guideline 2024).

If that is not enough, most grade 1 and 2 hemorrhoids, and some grade 3 ones, can be treated in a clinic. Banding is the most effective of these clinic treatments (ASCRS guideline 2024). A doctor places a small rubber band around the base of the hemorrhoid, which cuts off its blood supply so it shrivels and falls off, usually within a week (NIDDK). Large hemorrhoids, or ones that do not respond, may need surgery to remove them (NHS).

Prolapsed hemorrhoids

A prolapsed hemorrhoid is an internal hemorrhoid that has bulged out through the opening. Before it prolapses you usually cannot feel it. Once it is out, you may notice bleeding, itching, mucus, pain when you sit, or a feeling that something is stuck after you wipe (Cleveland Clinic).

If it comes out and stays out after the toilet, you can try to gently push it back inside (NHS). Use a clean finger and a little lubricant, and press slowly. Do not force it.

Rarely, the muscles around the opening squeeze a prolapsed hemorrhoid and cut off its blood supply. This is called a strangulated hemorrhoid (NIDDK). If a lump will not go back and turns dark, hard or very painful, get medical care the same day.

External hemorrhoids

External hemorrhoids sit under the skin around the opening, so they are easier to notice. Signs include itching, one or more tender lumps near the opening, and an ache that is worse when you sit (NIDDK). They can sometimes bleed when you wipe (Cleveland Clinic).

They can also make the area harder to clean, which leaves the skin irritated (ASCRS guideline 2024). Rubbing, straining and too much cleaning can make symptoms worse. For many people, a flare-up calms down within a few days (NIDDK). Clean gently with water, pat dry rather than rub, and keep your stools soft (NHS). A warm bath can ease the itching and pain. Our guide on how to take a sitz bath shows you how.

Thrombosed hemorrhoids

A thrombosed hemorrhoid is a hemorrhoid with a blood clot inside. It usually happens in an external hemorrhoid. You notice a sudden, hard, very painful lump at the edge of the opening, often bluish or purple. It can hurt to sit, walk or open your bowels (Cleveland Clinic). The clot stays in that spot. It does not travel to other parts of your body (Cleveland Clinic).

The pain is usually worst in the first two days or so. Most thrombosed hemorrhoids get better with home care over a few weeks, as the body slowly breaks the clot down (Cleveland Clinic). Cold packs wrapped in a cloth, warm baths, soft stools and simple pain relief all help (NHS; Cleveland Clinic).

It is still worth seeing a doctor quickly, ideally within the first few days. For some people, removing the hemorrhoid early in a small procedure gives faster relief and makes it less likely to come back than waiting it out (ASCRS guideline 2024). Never try to drain one yourself (Cleveland Clinic). Get help the same day if you have a fever, or the lump keeps getting bigger, darker or harder, as it can become infected (Cleveland Clinic).

For how long each type usually takes to settle, see how long do hemorrhoids last.

What does a hemorrhoid look and feel like?

Hemorrhoids can be as small as a pea or as large as a grape, and pink or purple in color (NHS). The details depend on the type (Cleveland Clinic; Cleveland Clinic):

• Internal (not prolapsed): nothing to see or feel. You may only notice blood.
• Prolapsed internal: a soft, fleshy bump that comes out of the opening. It is skin-coloured or pinkish red, may leak a little clear mucus, and can often be pushed back in.
• External: a soft, skin-coloured lump right at the edge of the opening that you cannot push back in. When it flares up it can feel swollen, tender or firmer.
• Thrombosed external: a firm lump that is blue, purple or almost black, that appeared within a day or two and hurts a lot.

It can be hard to work this out on your own body. The Sitwell app helps you find your type with plain pictures of what each one looks and feels like, so you can match what you notice without looking at photos. Not every lump is a hemorrhoid, so if you are unsure, ask a doctor to take a look (Cleveland Clinic).

Hemorrhoid vs skin tag vs anal fissure

Two other common problems are often mistaken for hemorrhoids.

Skin tags are soft folds of loose skin around the opening. They are harmless and often linked to hemorrhoids. Some are skin left behind after an external hemorrhoid has settled. Skin tags can itch or make cleaning harder, but they do not bleed (Coventry and Rugby GP Gateway, NHS).

An anal fissure is a small tear in the skin of the anus. The main sign is a severe, sharp pain when you pass stool, often followed by a burning pain that can last for hours. It can also cause bright red blood (NHS). Hemorrhoids and fissures can both itch, hurt and bleed, and both are linked to straining and hard stools (Cleveland Clinic).

Sources: NHS, Coventry and Rugby GP Gateway, NHS, NIDDK.

When to see a doctor

Rectal bleeding is usually caused by hemorrhoids, but it should not be assumed. The same symptoms can come from other bowel problems, including inflammatory bowel disease and bowel cancer (NIDDK; ASCRS guideline 2024).

Get medical help today (emergency department, urgent care, or your local emergency number) if you have:

• Heavy bleeding that does not stop, or you are passing blood clots
• Bleeding with feeling faint, dizzy or short of breath
• Severe pain with a fever, or a lump that is quickly getting bigger, darker or harder

Book a doctor visit in the next few days if you have:

• Black or tar-like stools, or dark blood mixed into the stool
• Weight loss without trying, or unusual tiredness
• A change in bowel habit lasting more than 3 weeks (looser, more often, or new constipation)
• Bleeding that no doctor has examined, and you are over 45 or have bowel cancer in the family

Also see a doctor if your symptoms are getting worse, keep coming back, or have not improved after a week of home care. Ask for an urgent appointment if pus is leaking from the area, or you have a high temperature or feel hot, shivery and unwell (NHS; NIDDK). Our guide on bleeding hemorrhoids and when to see a doctor goes into more detail. If you are pregnant or have just had a baby, see hemorrhoids during pregnancy and after birth.

A doctor can usually tell the type just by looking and by a gentle examination with a gloved finger. Sometimes they use a short tube with a light to see inside (Cleveland Clinic). It is a quick check, and doctors do it every day.