Hemorrhoids: Internal vs. External and How to Treat Them

Most people think hemorrhoids are just an embarrassing nuisance-but they’re actually a common medical condition affecting 75% of adults at some point in their lives. The real problem? Many don’t know the difference between internal and external hemorrhoids, or how to treat them properly. And that confusion leads to delayed care, unnecessary pain, and sometimes serious mistakes.

What Exactly Are Hemorrhoids?

Hemorrhoids aren’t "swollen veins" in the way you might imagine. They’re normal vascular cushions inside and around your anus that help control stool passage. Think of them like shock absorbers for your rectum. But when pressure builds up-from straining, sitting too long, pregnancy, or chronic constipation-these cushions swell, inflame, and become painful or bleeding problems.

The key to understanding them is location. Hemorrhoids are divided by the dentate line, a natural boundary inside the anal canal. Above it? Internal. Below it? External. And that tiny difference changes everything-especially how they feel and how they’re treated.

Internal Hemorrhoids: Silent but Not Harmless

Internal hemorrhoids form inside the rectum, above the dentate line. The tissue there has no pain receptors. That’s why you might not feel them… until you do.

Their main sign? Bright red blood. You’ll see it on toilet paper, in the bowl, or streaking your stool. No pain. No lump. Just bleeding. That’s why so many people ignore it-until the bleeding gets worse.

Doctors grade internal hemorrhoids on a scale of I to IV:

• Grade I: Bleeds but doesn’t prolapse (protrude)
• Grade II: Prolapses during bowel movements but pops back in on its own
• Grade III: Prolapses and needs to be pushed back in manually
• Grade IV: Stays outside permanently and can’t be pushed back

Grade III and IV are the ones that cause real discomfort-not because they hurt, but because they get irritated, wet, and stuck. You might feel pressure, fullness, or a sense that you haven’t finished going.

External Hemorrhoids: Painful and Hard to Ignore

External hemorrhoids form under the skin around the anus. That area is packed with nerves. So when they swell, you know it.

Symptoms? Itching, burning, swelling, and a tender lump you can feel. Sometimes they look like a soft, skin-colored bump. Other times, they turn into a hard, purple or blue lump-that’s a thrombosed external hemorrhoid. It means a blood clot formed inside the vein. That’s when the pain hits hard: sharp, throbbing, and worse when you sit.

Unlike internal hemorrhoids, external ones rarely bleed. But they can rupture and ooze, especially if you wipe too hard or strain. The pain peaks within 48 hours and can last for days. Many people delay treatment because they’re embarrassed. But waiting too long makes it worse.

Can You Have Both at Once?

Yes. In fact, it’s common. Most people with hemorrhoids have a mix of internal and external types. That’s why symptoms can be confusing. You might bleed (internal) and also feel a painful lump (external). Or you think it’s just one thing-until the pain gets worse and you realize there’s more going on.

This is why self-diagnosis is risky. A lot of people mistake anal fissures (tiny tears in the skin) for hemorrhoids. Fissures cause sharp, tearing pain during bowel movements-not itching or swelling. They don’t usually bleed much, but the pain is intense. Treat a fissure like a hemorrhoid? You’ll keep hurting.

What Causes Hemorrhoids?

It’s not just sitting too long on the toilet. Though that helps. The real triggers:

• Chronic constipation and straining
• Chronic diarrhea
• Pregnancy (up to 35% of pregnant women get them)
• Obesity
• Heavy lifting
• Sitting for long periods (especially on hard surfaces)

Your bowel habits matter more than you think. Straining increases pressure in the rectal veins by 50% or more. Sitting on the toilet for 10+ minutes? That’s like holding a weight against your pelvic floor. Use a small footstool to raise your knees above your hips-it reduces pressure by about 30%.

Home Treatments That Actually Work

For mild cases, you don’t need surgery. Start here:

• High-fiber diet: Aim for 25-30 grams daily. Think beans, oats, berries, broccoli, chia seeds. Most people get less than half that.
• Drink water: 8-10 glasses a day. Fiber without water makes constipation worse.
• Sitz baths: Sit in warm (not hot) water for 15-20 minutes, 2-3 times a day. It reduces swelling and soothes irritation.
• Witch hazel pads: Apply after bowel movements to reduce itching and inflammation.
• Hydrocortisone cream (1%): Use sparingly for itching. Don’t use for more than a week without checking with a doctor.

Avoid harsh wipes, scented soaps, and vigorous wiping. Use unscented moist wipes or a bidet if you can.

When You Need More Than Home Care

If home treatments don’t help in 1-2 weeks, or if you’re bleeding heavily, it’s time for medical help.

For internal hemorrhoids, doctors have minimally invasive options:

• Rubber band ligation: A tiny band is placed around the base of the hemorrhoid. It cuts off blood flow. The hemorrhoid shrinks and falls off in 5-7 days. Success rate: 90% for Grades I-III. You might feel pressure or mild cramping for a day or two.
• Sclerotherapy: A chemical is injected to shrink the vein. Less effective than banding but less painful.
• Infrared coagulation: Heat is used to scar the tissue and shrink the hemorrhoid. Good for smaller ones.

For thrombosed external hemorrhoids, the best option is a quick procedure: a small cut to drain the clot. Do it within 72 hours of pain starting, and you’ll feel relief fast. Waiting? You might end up with a skin tag that stays forever.

Surgery: When Nothing Else Works

If you have Grade IV hemorrhoids, recurrent problems, or severe pain that won’t quit, surgery may be needed.

• Hemorrhoidectomy: The hemorrhoid is surgically removed. It’s the most effective treatment-95% success rate. But recovery takes 2-4 weeks. Pain is significant for the first week. You’ll need prescription pain meds.
• Stapled hemorrhoidopexy: Used for prolapsed internal hemorrhoids. The tissue is lifted and stapled back into place. Less pain than removal, but higher chance of recurrence.

Most people who get surgery do so because they’ve tried everything else. Don’t rush into it-but don’t avoid it if your quality of life is suffering.

What Not to Do

There’s a flood of online products promising "miracle cures" for hemorrhoids: creams, supplements, teas, devices. Most are useless. Some are dangerous.

The American Gastroenterological Association and the American Society of Colon and Rectal Surgeons warn against products that claim to "cure" hemorrhoids overnight. They’re not regulated. They don’t work. And they delay real treatment.

Also, never assume rectal bleeding is just hemorrhoids. It could be colon cancer, inflammatory bowel disease, or an infection. If you’re over 50, have a family history, or notice changes in bowel habits-get checked. Bleeding is never normal.

Prevention Is the Real Cure

The best treatment is avoiding hemorrhoids in the first place.

• Don’t sit on the toilet longer than 5 minutes.
• Don’t strain. If you don’t go after 5 minutes, get up and try later.
• Exercise regularly. Walking helps.
• Keep your weight healthy.
• For pregnant women: sleep on your left side, do pelvic floor exercises, and avoid constipation.

Studies show that people who stick to these habits have only a 5-10% chance of recurrence after treatment. Those who don’t? Up to 50% get them again.

When to See a Doctor

Call your doctor if you have:

• Bleeding that doesn’t stop or gets worse
• Pain that doesn’t improve after a week of home care
• A lump that won’t go away
• Dizziness, weakness, or signs of anemia (from blood loss)
• Changes in bowel habits, like diarrhea or constipation that lasts more than a few days
• Rectal bleeding for the first time after age 50

Waiting doesn’t make it go away. It just makes treatment harder.

If you’ve been living with hemorrhoids for months-or years-know this: you don’t have to suffer. The treatments work. The lifestyle changes make a difference. And seeing a doctor isn’t a sign of weakness-it’s the first step to feeling normal again.