Haemorrhoids are one of the most common anorectal conditions. Almost half of people will experience them by age 50, yet many people are unsure about the difference between internal and external haemorrhoids. The confusion is understandable: both conditions involve swollen blood vessels in the rectum or anus, but their location, symptoms, and treatment are quite different.
In this guide, we’ll break down what haemorrhoids are, how to know whether yours are internal or external, the causes, available treatments, prevention strategies, and the signs that mean it’s time to see a doctor.
What Are Haemorrhoids?
Haemorrhoids are swollen blood vessels that form in and around the rectum and anus. They develop when pressure builds up in the lower rectal veins, causing them to stretch and bulge.
Normally, these vascular cushions help with stool control. But when they enlarge or become irritated, they cause symptoms like bleeding, itching, swelling, or pain.
There are two main types: internal haemorrhoids (inside the rectum) and external haemorrhoids (under the skin around the anus).
Internal Vs External Haemorrhoids
The key difference lies in where the swollen vessels are located.
- Internal haemorrhoids form inside the rectum, above a line called the dentate (pectinate) line. They’re covered by mucosa and supplied by visceral nerves, which means they are usually painless even when bleeding.
- External haemorrhoids form under the skin around the anus, below the dentate line. They’re covered by skin and have somatic nerve supply, so they can be very painful, especially if a clot (thrombosis) develops.
Internal Haemorrhoids
Location
Internal haemorrhoids sit inside the rectum, above the dentate line. They’re not visible from outside unless they prolapse (slip down through the anus).
Symptoms
- Bright red bleeding during or after bowel movements.
- Mucus discharge.
- A feeling of incomplete evacuation.
- Prolapse (lump protruding out of the anus during straining).
- Usually no pain, unless prolapsed and trapped.
Grading (Goligher Classification)
- Grade I: No prolapse, just prominent vessels.
- Grade II: Prolapse occurs when straining, but returns on its own.
- Grade III: Prolapse that requires manual pushing back.
- Grade IV: Permanently prolapsed and cannot be reduced.
External Haemorrhoids
Location
External haemorrhoids form under the skin around the anus, below the dentate line. They are visible and can be felt as lumps near the anal opening.
Symptoms
- Pain or tenderness, especially when sitting
- Swelling or a lump around the anus
- Itching or irritation
- Bleeding if the skin breaks
- A bluish or purplish painful lump if thrombosed
Grading
External haemorrhoids are not graded like internal ones. They are instead described as:
- Simple external haemorrhoids: swollen skin and vessels.
- Thrombosed external haemorrhoid: a painful blood clot under the skin.
How to Know If a Haemorrhoid is Internal or External?
- Pain: Painful lumps are usually found on the outside of the body. If you notice bleeding that doesn’t hurt, it may come from inside the body.
- Location: A lump inside the rectum that you cannot see is internal. A lump at the anal opening that you can see or feel is external.
- Bleeding: Internal haemorrhoids cause bright red bleeding during bowel movements; external haemorrhoids may bleed if the skin breaks.
- Prolapse: Internal haemorrhoids can prolapse and appear outside, but they look red and moist (mucosa). External ones look like skin-covered lumps.
If you’re unsure, a doctor can confirm with a quick examination using anoscopy or proctoscopy.
What Causes Haemorrhoids?
Several factors increase the risk of haemorrhoids by raising pressure in the lower rectal veins:
- Cause Chronic constipation and straining
- Sitting on the toilet for long periods
- Low-fibre diet
- Chronic diarrhoea
- Pregnancy and childbirth
- Obesity
- Heavy lifting
- Ageing (weakened supportive tissues)
In rare cases, rectal bleeding may be caused by conditions other than haemorrhoids (polyps, colorectal cancer, inflammatory bowel disease), which is why medical evaluation is important if symptoms are unusual or persistent.
How Haemorrhoids Are Diagnosed?
Doctors usually diagnose haemorrhoids with a combination of history, physical exam, and, if needed, simple procedures:
- Medical History
Your doctor will first ask about your symptoms, diet, bowel habits, use of laxatives or enemas, and any existing health conditions.
- Physical Examination
- Visual Check: The area around the anus is inspected for external haemorrhoids, swelling, or irritation.
- Digital Rectal Exam (DRE): A gloved, lubricated finger is gently inserted into the rectum to feel for internal haemorrhoids, lumps, or other abnormalities.
- Anoscopy
If internal haemorrhoids are suspected, a short lighted tube (anoscope) is inserted into the rectum to provide a direct view of the anal canal and lower rectum.
- Sigmoidoscopy or Colonoscopy
For ongoing bleeding or unexplained symptoms, your doctor may recommend a sigmoidoscopy (to examine the lower colon) or a colonoscopy (to examine the entire colon). These tests rule out more serious conditions like polyps or colorectal cancer.
Medical Treatment for Haemorrhoids
1. Rubber Band Ligation (RBL)
One of the most common office treatments for internal haemorrhoids. A small rubber band is placed at the base of the haemorrhoid, cutting off its blood supply. Within a week, the haemorrhoid shrivels and falls off.
- Best for: Grade II and III internal haemorrhoids.
- Advantages: Quick, effective, no anaesthesia needed and less recovery time
- Possible downsides: Mild pain or pressure, light bleeding after a few days. Rarely, infection or severe bleeding.
2. Haemorrhoidectomy
This is the surgical removal of haemorrhoids, usually done under anaesthesia. The surgeon cuts away the enlarged tissue and closes the wound.
- Best for: Large external haemorrhoids, Grade IV internal haemorrhoids, or cases that don’t respond to other treatments.
- Advantages: Most effective long-term solution, lowest recurrence rates.
- Possible downsides: Painful recovery, risk of infection, longer healing time (2-4 weeks).
3. Haemorrhoidal Artery Ligation (HALO / THD)
Also called Doppler-guided haemorrhoidal artery ligation, this procedure uses an ultrasound probe to locate the arteries supplying the haemorrhoids. The surgeon ties off (ligates) these arteries, reducing blood flow. Sometimes, the prolapsed tissue is stitched back in place (mucopexy).
- Best for: Internal haemorrhoids with prolapse (Grades II–III).
- Advantages: Less painful than a traditional haemorrhoidectomy, faster recovery.
- Possible downsides: Slightly higher recurrence compared to excision surgery.
4. LHP – Laser Haemorrhoidoplasty
A modern, minimally invasive technique that uses laser energy to shrink haemorrhoidal tissue from the inside. The laser seals blood vessels and reduces the haemorrhoid’s size over time.
- Best for: Symptomatic internal haemorrhoids.
- Advantages: Minimal pain, less bleeding, faster healing, outpatient procedure.
- Possible downsides: Higher cost, availability limited to specialised centres.
5. Sclerotherapy
A chemical solution is injected into the haemorrhoid, causing the veins to scar and shrink.
- Best for: Small internal haemorrhoids (Grade I–II) and patients who can’t undergo banding.
- Advantages: Quick, simple, minimal discomfort.
- Possible downsides: May require repeat sessions, less effective for larger haemorrhoids.
6. Infrared Coagulation (IRC)
A probe applies bursts of infrared light (heat) to the haemorrhoid base, causing the tissue to coagulate and shrink.
- Best for: Small bleeding internal haemorrhoids.
- Advantages: Painless, outpatient, minimal recovery time.
- Possible downsides: Recurrence is more common compared to rubber band ligation.
Internal and External Haemorrhoids Treatment at Home
Most mild haemorrhoids can be managed at home with simple lifestyle changes and self-care. The goal is to make bowel movements easier, reduce irritation, and relieve discomfort.
1. Improve Diet and Hydration
- Add more fibre: Include fruits, vegetables, whole grains, or fibre supplements like psyllium (Metamucil) to soften stools and make them easier to pass.
- Drink enough fluids: Staying well-hydrated with water and nonalcoholic drinks helps prevent constipation.
2. Change Toilet Habits
- Avoid straining: Straining increases pressure on haemorrhoids and worsens symptoms.
- Limit toilet time: Don’t sit for long periods on the toilet.
- Elevate your feet: Using a small stool to lift your feet creates a squatting position, which can make bowel movements smoother.
3. Stay Active
Light exercise, such as walking, improves digestion and lowers the risk of constipation.
4. Comfort and Symptom Relief
- Sitz baths: Sitting in warm water for 10-20 minutes a few times daily can ease pain and itching.
- Cold compresses: Applying an ice pack wrapped in a cloth helps reduce swelling and discomfort.
- Topical treatments: Over-the-counter creams or ointments with lidocaine (for pain), hydrocortisone (for swelling and itching), or witch hazel (for soothing and shrinking tissue) can provide quick relief.
5. Maintain Good Hygiene
Keep the anal area clean by gently wiping with damp, alcohol-free wipes or moistened toilet paper after bowel movements to avoid irritation.
When to See a Doctor?
You should see a doctor if you have:
- Heavy or recurrent rectal bleeding
- Dark or tarry stools
- Severe anal pain or swelling
- A lump that doesn’t go away
- Signs of anaemia (fatigue, dizziness, pale skin)
- Family history of colorectal cancer
Prompt evaluation rules out other conditions and ensures you get the right treatment.
Final Thoughts
Internal and external haemorrhoids may sound similar, but their location, symptoms, and treatments differ significantly. Fortunately, most cases improve with lifestyle changes, simple home remedies, and, if needed, quick outpatient procedures.
Prevention is the best long-term solution. You can help avoid haemorrhoids by eating enough fibre, drinking plenty of water, and practising healthy bowel habits. Haemorrhoids are common and usually not serious, but if you experience bleeding or pain, see a doctor for evaluation.
Frequently Asked Questions
1. Do haemorrhoids go away on their own?
Yes, mild cases often resolve with lifestyle changes. Persistent or severe haemorrhoids may need medical treatment.
2. Can haemorrhoids be permanently cured?
Surgery offers the most definitive cure, but many people manage well long-term with diet and preventive measures.
3. Are haemorrhoids dangerous?
They’re not usually dangerous, but rectal bleeding should always be checked to rule out other conditions.
4. What’s the fastest way to relieve haemorrhoid pain?
A sitz bath and over-the-counter creams can quickly soothe discomfort. For thrombosed external haemorrhoids, minor surgical removal may provide rapid relief.
5. Do haemorrhoids increase cancer risk?
Haemorrhoids do not cause cancer, but they can show symptoms that are similar to more serious issues. If you experience persistent bleeding, it is important to see a doctor for evaluation.
