Introduction
Hemorrhoids are swollen veins in the lower rectum and anus—similar to varicose veins that can occur in the legs. They are incredibly common, affecting nearly 1 in 20 adults, and about 50% of people over age 50 experience them at some point. Hemorrhoids are typically classified as either internal or external, depending on their location.
Understanding the differences between internal and external hemorrhoids is crucial for accurate diagnosis, effective treatment, and symptom relief. This article explores the key differences, common symptoms, causes, and best treatment options for both types.
What Are Hemorrhoids?
Hemorrhoids develop when the veins around the anus or lower rectum become enlarged due to increased pressure. Common contributing factors include:
- Straining during bowel movements
- Chronic constipation or diarrhea
- Sitting for long periods (especially on the toilet)
- Pregnancy
- Obesity
- Low-fiber diets
There are two main types of hemorrhoids:
- Internal hemorrhoids: Located inside the rectum
- External hemorrhoids: Located under the skin around the anus
Both types can occur simultaneously and present different symptoms and treatment challenges.
Internal Hemorrhoids
Location and Description
Internal hemorrhoids form inside the rectum, usually about 2–4 cm above the opening of the anus. Since this area lacks pain receptors, these hemorrhoids are often painless, even when they bleed.
Symptoms
- Painless rectal bleeding (bright red blood on toilet paper or in the toilet bowl)
- Prolapse: Hemorrhoids that protrude through the anal opening, especially during bowel movements
- Mucus discharge
- Itching or irritation if prolapsed
Grading of Internal Hemorrhoids
Doctors classify internal hemorrhoids into four grades:
- Grade I: No prolapse; only visible via scope
- Grade II: Prolapse with straining but retracts on its own
- Grade III: Prolapse that requires manual pushing back
- Grade IV: Permanently prolapsed and cannot be pushed back
External Hemorrhoids
Location and Description
External hemorrhoids develop under the skin around the anus, where there are many nerve endings. This makes them often painful or tender, especially when inflamed or thrombosed (filled with clotted blood).
Symptoms
- Pain or discomfort, especially when sitting
- Swelling or a hard lump near the anus
- Bleeding during bowel movements
- Itching or irritation around the anal area
- Thrombosed hemorrhoid: Severe pain, blue or purple lump, swelling
Key Differences Between Internal and External Hemorrhoids
| Feature | Internal Hemorrhoids | External Hemorrhoids |
| Location | Inside the rectum | Under the skin around the anus |
| Pain | Usually painless | Often painful, especially if thrombosed |
| Bleeding | Common, bright red blood | Possible, but less common |
| Prolapse | May protrude outside the anus | Do not prolapse |
| Itching/Irritation | Mild, mostly with prolapse | More common due to skin irritation |
| Treatment Approach | Often managed conservatively or with procedures | Typically treated with creams, warm baths, or minor surgery |
Causes and Risk Factors
- Constipation and straining
- Low-fiber diets
- Prolonged sitting
- Pregnancy and childbirth
- Heavy lifting
- Aging, which weakens tissues
Diagnosis
A healthcare provider may perform:
- Physical exam (for external hemorrhoids)
- Digital rectal exam
- Anoscopy or proctoscopy (to view internal hemorrhoids)
- Colonoscopy (if bleeding needs further investigation)
Treatment Options
Home and Conservative Treatments
These apply to both types of hemorrhoids, especially mild cases:
- High-fiber diet (fruits, vegetables, whole grains)
- Increased fluid intake
- Stool softeners or fiber supplements (e.g., psyllium)
- Avoid straining during bowel movements
- Warm sitz baths: 10–15 minutes, several times a day
- Over-the-counter creams and ointments (e.g., hydrocortisone, witch hazel)
Medications
- Topical anesthetics: To relieve itching or pain
- Oral pain relievers: Acetaminophen or ibuprofen for discomfort
Medical Procedures for Internal Hemorrhoids
Used when conservative treatments fail, especially for Grades II–IV:
- Rubber band ligation: A rubber band is placed around the hemorrhoid to cut off blood flow, causing it to shrink and fall off.
- Sclerotherapy: Injection of a chemical solution to shrink the hemorrhoid.
- Infrared coagulation (IRC): Uses infrared light to clot and shrink the hemorrhoid.
- Hemorrhoidectomy: Surgical removal, usually for severe or Grade IV hemorrhoids.
- Stapled hemorrhoidopexy: A less painful surgical option to reposition prolapsed hemorrhoids.
Medical Procedures for External Hemorrhoids
- Thrombectomy: If the external hemorrhoid is thrombosed, the clot may be removed under local anesthesia.
- Hemorrhoidectomy: For persistent or severe external hemorrhoids.
When to See a Doctor
Seek medical attention if:
- You have persistent bleeding
- Pain becomes severe
- There’s a lump or swelling that doesn’t improve
- Symptoms don’t respond to at-home treatments
- You experience black or tarry stools (may indicate a different issue)
Prevention Tips
- Eat a fiber-rich diet and drink plenty of water.
- Don’t delay bowel movements.
- Avoid sitting too long, especially on the toilet.
- Exercise regularly to prevent constipation.
- Use proper lifting techniques.
- Keep the anal area clean and dry.
Conclusion
Internal and external hemorrhoids share some similarities but differ in location, symptoms, and treatment strategies. While internal hemorrhoids are often painless and may bleed, external hemorrhoids can cause significant discomfort and swelling. Most hemorrhoids can be managed with lifestyle changes and over-the-counter remedies, but more persistent or severe cases may require medical or surgical intervention.
Understanding the type of hemorrhoid you’re experiencing is the first step toward finding effective relief. If in doubt, always consult a healthcare provider for proper diagnosis and treatment.
FAQs:
What’s the main difference between internal and external hemorrhoids?
Internal hemorrhoids are located inside the rectum and are usually painless; external hemorrhoids are under the skin around the anus and often cause pain or discomfort.
Can internal hemorrhoids be felt or seen?
Not usually—unless they prolapse outside the anus during bowel movements, in which case they may be visible or felt as soft lumps.
Are external hemorrhoids more painful than internal ones?
Yes, external hemorrhoids tend to be more painful, especially if they become thrombosed (clotted).
Can both internal and external hemorrhoids bleed?
Yes, but bleeding from internal hemorrhoids is more common and typically painless. External hemorrhoids may bleed if irritated.
When should I see a doctor for hemorrhoids?
See a doctor if you experience severe pain, persistent bleeding, prolapse, or if symptoms don’t improve with home treatments.
