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