Hemorrhoids: Internal vs. External and How to Treat Them

Most people think hemorrhoids are just an embarrassing annoyance-but they’re actually a common medical condition that affects 75% of adults at some point in their lives. The truth? You might already have them and not even know it. The real problem isn’t having hemorrhoids-it’s not knowing whether they’re internal or external, and what to do about them.

What Exactly Are Hemorrhoids?

Hemorrhoids aren’t some weird growth or infection. They’re normal blood vessels in your rectum and anus that help control stool passage. Think of them like little cushions that swell up when under too much pressure. When they get irritated or stretched out-thanks to constipation, pregnancy, sitting too long, or heavy lifting-they become painful or bleed. That’s when they turn from helpful structures into a problem.

The key to treating them right is knowing where they are. There are two main types: internal and external. And they’re not just different in location-they feel completely different, need different treatments, and can be easily confused with other issues.

Internal Hemorrhoids: The Silent Ones

Internal hemorrhoids sit inside the rectum, above a line called the dentate line. This area has no pain nerves, so even when they swell, you often won’t feel pain. That’s why many people don’t realize they have them until they see bright red blood on the toilet paper or in the bowl after a bowel movement.

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

• Grade I: Just swollen. Bleeds sometimes, but doesn’t pop out.
• Grade II: Protrudes during straining but pops back in on its own.
• Grade III: Comes out and stays out-but you can push it back in.
• Grade IV: Stays out permanently. Can’t be pushed back. Often very uncomfortable.

The biggest danger with internal hemorrhoids? People assume all rectal bleeding is harmless. But bleeding can also signal colon cancer, inflammatory bowel disease, or other serious conditions. If you’re seeing blood regularly-even if you think it’s just hemorrhoids-get it checked.

External Hemorrhoids: The Painful Ones

External hemorrhoids form under the skin around your anus. This area is packed with nerves, so even a small swelling can feel like a throbbing, burning, or stabbing pain. You’ll likely see or feel a soft, skin-colored lump near your anal opening.

The worst kind? Thrombosed external hemorrhoids. This happens when a blood clot forms inside the swollen vein. It turns into a hard, purple or blue lump that feels like a marble under your skin. The pain hits fast and hard-often making sitting, walking, or even lying down unbearable.

Unlike internal hemorrhoids, external ones rarely bleed. Instead, they cause itching, swelling, and sharp pain that gets worse when you sit or wipe. Many people delay seeing a doctor because they think it’s just a pimple or irritation. But thrombosed hemorrhoids need quick attention-especially within the first 72 hours.

Can You Have Both at Once?

Yes. And it’s more common than you think. Many people have a mix: an internal hemorrhoid that’s prolapsed (sticking out) and an external one right next to it. This makes symptoms confusing. You might have bleeding from inside, plus pain and swelling from outside.

That’s why self-diagnosis is risky. One patient I spoke with spent six months treating what he thought was an external hemorrhoid with creams and sitz baths. Turns out, it was an anal fissure-a small tear in the lining. The treatments were useless. He only got relief after a doctor did a visual exam.

What Causes Hemorrhoids?

It’s not just “eating too little fiber.” While that’s a big part, other factors pile up:

• Chronic constipation or diarrhea
• Straining during bowel movements
• Sitting on the toilet longer than 5 minutes
• Pregnancy (25-35% of pregnant women get them)
• Obesity
• Heavy lifting
• Aging (tissues lose support over time)

The real kicker? Sitting on the toilet for too long increases pressure in your rectal veins by up to 30%. That’s why using a small footstool to raise your knees above your hips helps-it mimics a squatting position, which is how our bodies were meant to go to the bathroom.

Home Treatments That Actually Work

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

• Drink more water. Aim for 8-10 glasses a day. Dehydration hardens stool, which means more straining.
• Eat 25-30 grams of fiber daily. Oats, beans, apples, broccoli, chia seeds, and whole grains help. Most people get less than half that.
• Take sitz baths. Sit in warm (not hot) water for 15-20 minutes, 2-3 times a day. It reduces swelling and soothes irritation.
• Use witch hazel pads. They’re gentle, anti-inflammatory, and available over the counter.
• Avoid straining. If you don’t go after 5 minutes, get up. Try again later.

Over-the-counter creams with hydrocortisone can help itching and inflammation-but don’t use them for more than a week. Long-term use can thin your skin.

When You Need Medical Help

If home care doesn’t help in a week or two, or if symptoms get worse, it’s time to see a doctor. Here’s when to act:

• Rectal bleeding that keeps coming back
• Pain so bad you can’t sit or walk
• A lump that won’t go away or gets bigger
• Dizziness, fatigue, or pale skin (signs of blood loss)
• Changes in bowel habits (new constipation, diarrhea, narrow stools)

Don’t ignore these. Bleeding isn’t always hemorrhoids. Colorectal cancer can mimic the same symptoms.

Minimally Invasive Procedures

For internal hemorrhoids that don’t respond to lifestyle changes, doctors have several safe, office-based options:

• Rubber band ligation: A tiny band is placed around the base of the hemorrhoid, cutting off blood flow. It shrinks and falls off in a few days. Works in 90% of cases for Grades I-III.
• Sclerotherapy: A chemical solution is injected into the hemorrhoid to shrink it.
• Infrared coagulation: Heat is applied to scar the tissue and shrink the vein.

These are quick, usually painless, and let you go home the same day. Rubber band ligation might cause mild pressure or cramping for a day or two. But it’s far easier than surgery.

Thrombosed External Hemorrhoids: The Emergency Fix

If you’ve got a sudden, hard, purple lump that’s throbbing with pain, don’t wait. See a doctor within 72 hours. The best treatment? A small incision to drain the clot. Done under local numbing, it takes 10 minutes and gives almost instant relief.

Waiting longer than 3 days? The clot starts to harden and heal on its own-but the pain lasts for weeks. And you’re left with a skin tag that can cause ongoing irritation.

Surgery: Last Resort, But Effective

For severe, recurrent, or Grade IV hemorrhoids, surgery may be needed. Two main options:

• Hemorrhoidectomy: The hemorrhoid is completely cut out. It’s the most effective method-95% success rate. But recovery takes 2-4 weeks. Pain is real, and you’ll need prescription painkillers.
• Stapled hemorrhoidopexy: The prolapsed tissue is pulled back up and stapled into place. Less pain than removal, but higher chance of recurrence.

Most people avoid surgery because they’re scared of the recovery. But if you’ve tried everything else and you’re still in pain, it’s worth considering.

Prevention Is the Real Cure

The biggest mistake people make? Treating the symptom, not the cause. Hemorrhoids come back if you don’t change your habits.

Studies show that people who stick to high-fiber diets and drink enough water have only a 5-10% chance of recurrence. Those who go back to bad habits? Up to 50% get them again.

Here’s what works long-term:

• Make fiber a daily habit-not just when you’re bleeding.
• Move your body. Even a 20-minute walk daily helps bowel function.
• Don’t sit on the toilet reading or scrolling. Set a timer.
• If you’re pregnant, sleep on your left side. It reduces pressure on pelvic veins.
• Ignore online “miracle cures.” No cream, oil, or supplement cures hemorrhoids. Only evidence-based treatments do.

Frequently Asked Questions

What to Do Next

If you’re dealing with bleeding, pain, or swelling, start with the basics: fiber, water, sitz baths, and no more than 5 minutes on the toilet. Give it a week. If nothing changes-or if symptoms worsen-see a doctor. Don’t wait months like so many others do. Early treatment means less pain, fewer procedures, and faster recovery.

Hemorrhoids aren’t shameful. They’re common. And with the right approach, they’re manageable-even preventable.