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Internal vs external haemorrhoids

Published 13 March 2026 ·Last reviewed 13 March 2026 by the editorial team ·How we create our content

At a glance

Haemorrhoids are swollen blood vessels in and around the anal canal. The distinction between internal and external haemorrhoids matters because they cause different symptoms, feel different, and may require different treatment approaches.

This guide explains the key differences in plain terms.

Where they are

Internal haemorrhoids

Located inside the anal canal, above the dentate line (a boundary in the anal canal)
Not visible from outside unless they prolapse
Cannot usually be felt by hand
Covered by the same type of tissue that lines the rectum

External haemorrhoids

Located outside the anal canal, below the dentate line
Visible at the anal margin when swollen
Can be felt as lumps
Covered by skin tissue, which contains more nerve endings

The dentate line

This is an anatomical landmark inside the anal canal that divides it into two zones with different types of tissue and different nerve supply. Above this line (where internal haemorrhoids are), there are fewer pain-sensing nerves. Below it (where external haemorrhoids are), there are more. This explains the difference in pain between the two types.

How they feel

Internal haemorrhoids

Often painless — the tissue they are in has limited pain sensation
Bleeding is the most common symptom — bright red blood during or after bowel movements
Prolapse — may push out during bowel movements, creating a feeling of something coming out
Mucus discharge — can cause dampness and irritation
A feeling of incomplete evacuation — as if the bowel movement is not complete

External haemorrhoids

Pain — especially when thrombosed (a blood clot forms inside)
Swelling — a visible or palpable lump at the anal margin
Itching — common and persistent
Discomfort when sitting or during activity
Bleeding — less common than with internal haemorrhoids but can occur if the skin over the haemorrhoid is irritated

Thrombosed external haemorrhoids

When a blood clot forms in an external haemorrhoid:

Sudden, severe pain
A firm, tender lump — often blue or purple in colour
Significant swelling
Pain that is typically worst in the first 48 to 72 hours and then gradually improves

Grading internal haemorrhoids

Internal haemorrhoids are classified by how much they prolapse:

Grade 1: Remain inside the anal canal. No prolapse. May cause painless bleeding.
Grade 2: Prolapse during bowel movements but retract on their own afterwards.
Grade 3: Prolapse during bowel movements and require manual pushing back (reduction).
Grade 4: Remain prolapsed and cannot be pushed back in.

The grade helps guide treatment decisions. Lower grades often respond to conservative management. Higher grades may require procedures or surgery.

Treatment differences

Conservative management (both types)

Dietary changes — fibre, hydration, soft stools
Avoiding straining
Sitz baths
Topical treatments for symptom relief
These measures help both internal and external haemorrhoids

Procedures for internal haemorrhoids

Rubber band ligation: A band placed around the haemorrhoid to cut off blood supply
Sclerotherapy: Injection to shrink the haemorrhoid
Infrared coagulation: Heat applied to reduce blood flow
These are typically office-based procedures for grades 1 to 3

Procedures for external haemorrhoids

Excision: Thrombosed external haemorrhoids may be excised (cut out) if seen within 48 to 72 hours of onset
Conservative management: Warm baths, pain relief, and time — most thrombosed external haemorrhoids resolve within one to two weeks

Surgery for severe cases

Haemorrhoidectomy: Surgical removal, typically for large or grade 3-4 haemorrhoids that do not respond to other treatments
Addresses both internal and external components

When to seek care

Contact your clinician if you experience:

Heavy rectal bleeding or blood clots
A painful, swollen lump that is not improving
Prolapse that cannot be pushed back in
Signs of anaemia — dizziness, fatigue, pallor
Symptoms that persist despite conservative management

Common questions

How do I know if I have internal or external haemorrhoids?

You often cannot tell by yourself. External haemorrhoids can sometimes be seen or felt as lumps at the anal margin. Internal haemorrhoids are inside the anal canal and are not visible or palpable unless they prolapse. A clinician can distinguish between them during an examination. The symptoms can overlap, so self-diagnosis is unreliable.

Which type is more painful?

External haemorrhoids tend to cause more pain, particularly when thrombosed (containing a blood clot). Internal haemorrhoids are often painless because the tissue inside the anal canal has fewer pain-sensing nerve endings. Internal haemorrhoids are more likely to cause painless bleeding, while external haemorrhoids are more likely to cause pain and itching.

Can you have both types at the same time?

Yes. It is common to have both internal and external haemorrhoids simultaneously. This is sometimes called mixed haemorrhoids. The treatment approach may address both components.

Do they need different treatments?

The underlying principles are similar — stool management, avoiding straining, and sitz baths help with both types. However, specific procedures differ. Internal haemorrhoids may be treated with banding, injection, or infrared coagulation. External haemorrhoids that are thrombosed may require excision. Your clinician will recommend treatment based on the specific type and severity.

Can internal haemorrhoids become external?

Internal haemorrhoids can prolapse — meaning they push out through the anal canal. When prolapsed, they can look and feel similar to external haemorrhoids. The grading system for internal haemorrhoids reflects this: Grade 1 stays inside, Grade 2 prolapses but retracts on its own, Grade 3 requires manual pushing back, and Grade 4 remains prolapsed.

When to seek care Heavy bleeding or feeling faint? Get emergency help now. Emergency: 911

Not sure how urgent it is? Get help today.

Emergency
Heavy bleeding, black tarry stools, feeling faint, severe pain or trouble breathing.

Call 911 or go to the ER.
Today
Fever, pain getting worse, a hot swollen lump, or trouble passing urine.

Call your doctor or go to urgent care.
Soon
Bleeding or bowel changes nobody has checked, or anything lasting 3 weeks.

Book a doctor’s appointment.

Feeling overwhelmed? Call or text 988, any time.

See all the signs

For this topic, get medical advice if you notice:

Heavy rectal bleeding or blood clots
Severe pain from a thrombosed haemorrhoid
Prolapse that cannot be pushed back in
Signs of anaemia such as dizziness or fatigue

Recording how you feel is not the same as being checked. These are the signs that need a doctor’s attention.

Call 911 or go to the emergency room now if you have:

bleeding that will not stop, a lot of blood (the toilet water turns red, or you pass large clots), or any bleeding with feeling faint or dizzy
fainting, a racing heart or trouble breathing
confusion or slurred speech, extreme shivering, no urine in a day, or blotchy skin
sudden severe belly pain, or a swollen, hard belly with vomiting or not passing stool or gas
you cannot pass urine at all, or your bladder feels full and painful and you can’t empty it
redness, swelling or severe pain spreading quickly around your anus, genitals or groin, especially with a fever or feeling very ill
a fever with a painful swelling near your anus if you have diabetes or a weakened immune system (for example, from chemotherapy or transplant medicines)
black, tarry stools

Call your doctor or go to urgent care today (or the ER if you can’t be seen today) if you have:

a temperature of 100.4°F (38°C) or higher, chills, vomiting, or feeling generally unwell
pain that is getting worse over days, or severe pain that stops you sitting or sleeping
a hot, swollen or very tender lump near your anus or at the top of the crease between your buttocks, or foul-smelling discharge
trouble urinating
bleeding that is getting heavier or more frequent, or blood mixed into your stool
feeling much more tired than usual, looking pale, or getting out of breath more easily than you used to
not passing stool for several days, or new belly pain

Make an appointment with your doctor if:

you have never had these symptoms checked by a doctor or nurse — whatever your age
you have had rectal bleeding for more than 3 weeks
your bowel movements have been looser, thinner or more frequent than usual for 3 weeks or more, or you have lost weight without trying
symptoms have not settled after a week or so, or keep coming back
you notice a new lump near your anus, between your buttocks or in your belly, or an itch or discharge that does not clear
you have new leakage or trouble controlling your bowels
you are 45 or over, or have a family history of bowel cancer or inflammatory bowel disease, and any of these symptoms are new for you

If you are unsure, it is always reasonable to ask. If things feel overwhelming, call or text 988 (Suicide & Crisis Lifeline) or chat at 988lifeline.org, any time. If you don’t feel safe, call 911.

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Related symptoms

Bleeding Pain during bowel movements Pain after bowel movements Itching Swelling or lump Pressure or fullness Protrusion

Discreet symptom tracking

Symptoms that come and go? Keep track, day by day.

For hemorrhoids, fissures, fistulas and other anal and rectal problems. A short, discreet email asks how things have been, and saves each answer, so you can look back at every flare and every good week in your own words. If you haven’t had your symptoms checked, see your doctor first.

About ten seconds a check-in. No app, no password.
Nothing in the subject or preview says what it’s about.
Each Sunday, a link to your week, ready for your next appointment.

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