What is the difference between internal and external hemorrhoids?

As per published NHS and ASCRS guidance (last checked Oct 2026), internal hemorrhoids form above the dentate line inside the rectum, where there is little pain sensation, so they often cause painless bleeding. External hemorrhoids form below the dentate line under the skin around the anus, which is richly supplied with pain nerves, so they can become very painful, especially if a blood clot forms (thrombosed).

What are the grades of internal hemorrhoids?

As per the published Goligher grading system referenced in ASCRS and NHS guidance (last checked Oct 2026): Grade I hemorrhoids bleed but do not prolapse; Grade II prolapse with straining but go back in on their own; Grade III prolapse and need to be pushed back in manually; Grade IV are permanently prolapsed and cannot be pushed back in. Grade generally guides which treatments are considered.

What is a thrombosed external hemorrhoid?

As per published guidance (last checked Oct 2026), a thrombosed external hemorrhoid is an external hemorrhoid in which a blood clot has formed, causing a firm, often bluish, very painful lump at the anus. Published sources describe it as often easing with conservative care (sitz baths, pain relief, stool softeners) over one to two weeks, though surgical removal within the first couple of days can relieve severe pain faster in some cases.

When does rectal bleeding need urgent medical review rather than being assumed to be hemorrhoids?

As per published NICE guidance (last checked Oct 2026), rectal bleeding should be assessed by a doctor rather than assumed to be hemorrhoids when it is new in someone over 50, associated with a change in bowel habit, unexplained weight loss, abdominal pain, iron-deficiency anaemia, or a family history of bowel cancer or inflammatory bowel disease. These features can indicate other conditions that need to be ruled out.

Understanding hemorrhoids

Internal vs External Hemorrhoids: What's the Difference?

Based on published NHS, ASCRS (American Society of Colon and Rectal Surgeons) and NICE guidance (last checked Oct 2026). General information only.

"Hemorrhoids" isn't one single thing — where they sit makes a big difference to what you'll notice and what treatment, if any, is typically considered. This page explains the difference in plain English, using published clinical sources. It is not a diagnosis. If you have symptoms, your doctor needs to examine you to know what's actually going on — some other conditions can look or feel similar.

This does not replace medical advice. Always seek proper medical advice from a qualified healthcare professional. This page summarises published clinical guidelines and does not assess your individual symptoms.

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Internal hemorrhoids

Location

Above the dentate line, inside the rectum, covered by mucosa (bowel lining) rather than skin.

Typical symptom

Painless bright-red bleeding, often noticed on toilet paper or in the bowl, especially with straining. Can also cause a sensation of prolapse (something coming down) with larger hemorrhoids.

Why usually painless

As per published anatomy references, the lining above the dentate line has very limited pain-sensing nerve supply, so internal hemorrhoids typically don't hurt unless they prolapse and become trapped, or thrombose.

Typically needs treatment when

Bleeding is recurrent, the hemorrhoid prolapses, or symptoms affect quality of life. See our banding vs surgery comparison for the options typically considered.

Often manageable with self-care when

Symptoms are mild, intermittent, and there's no bleeding pattern that needs checking (see red flags below).

External hemorrhoids

Location

Below the dentate line, under the skin around the anal opening.

Typical symptom

A lump you can feel or see, itching, irritation, and — if a clot forms inside it (thrombosed) — often significant pain.

Why often painful

As per published anatomy references, the skin below the dentate line is richly supplied with the same pain nerves as the rest of the skin, so swelling or clotting here is felt intensely.

Typically needs treatment when

Pain is severe (a thrombosed external hemorrhoid may be surgically removed within the first 48–72 hours in some cases) or skin tags/irritation persist.

Often manageable with self-care when

Mild irritation or a small, non-thrombosed external hemorrhoid — warm sitz baths, topical treatments and good hygiene are commonly recommended first.

The grading system for internal hemorrhoids (Grade I–IV)

As per the Goligher grading system referenced in published ASCRS and NHS sources (last checked Oct 2026), internal hemorrhoids are graded by how much they prolapse (come down) and whether they go back in on their own:

Grade I

Bleed, but do not prolapse or come down at all.

Grade II

Prolapse with straining or passing a bowel motion, but go back in by themselves afterward.

Grade III

Prolapse and need to be gently pushed back in with a finger — they don't reduce on their own.

Grade IV

Permanently prolapsed and cannot be pushed back in at all.

This grade is one of the main things your doctor or surgeon uses to decide which treatment (if any) is appropriate — see our hemorrhoid banding vs surgery comparison for how that typically maps to treatment choice.

⚠ What's a thrombosed external hemorrhoid?

As per published guidance (last checked Oct 2026), this happens when blood pools and clots inside an external hemorrhoid, creating a firm, often bluish, very tender lump at the anus — usually sudden in onset. Published sources describe it as generally one of the most painful (though not dangerous) things that can happen with hemorrhoids. It's commonly managed with warm sitz baths, pain relief, stool softeners and topical treatments, with most cases easing within one to two weeks as the clot is reabsorbed. If pain is severe, a doctor may offer to remove the clot or the hemorrhoid surgically, which is often most effective in the first couple of days.

⚠ When to get it checked urgently, rather than assuming "it's just hemorrhoids"

Rectal bleeding that is new, in someone over 50, or hasn't been medically assessed before
Bleeding together with a change in bowel habit (looser, more frequent, or thinner stools) lasting more than a few weeks
Unexplained weight loss, abdominal pain, or a feeling of incomplete emptying
Dark or black, tarry stools (this can indicate bleeding higher up the digestive tract, not hemorrhoids)
Symptoms of anaemia from ongoing blood loss: fatigue, breathlessness, looking pale
A family history of bowel cancer or inflammatory bowel disease

As per NICE guidance, any of these warrant medical assessment — sometimes including a colonoscopy — to rule out other causes before bleeding is put down to hemorrhoids. Emergency: 000 (AU) · 999 (UK) · 911 (US).

Common questions

Why don't internal hemorrhoids hurt?

As per published anatomy references, internal hemorrhoids sit above the dentate line, where the lining has very few pain-sensing nerves. That's why they typically cause painless bleeding rather than pain — unless they prolapse and become trapped, or develop a clot.

Can you have both internal and external hemorrhoids at once?

Yes — published sources describe this as common. Many people have a mix, which is one reason a doctor's examination matters: it determines exactly what's present and what, if anything, needs treating.

Is a thrombosed external hemorrhoid an emergency?

As per published guidance, it is painful but not generally dangerous. It's reasonable to see a doctor promptly for pain relief and to discuss options, but it is not the same as the red-flag bleeding symptoms above, which warrant more urgent assessment.

What treatments are typically used for each grade?

As per published ASCRS and NICE guidance, lower grades (I–II) are often managed with lifestyle changes or office procedures like banding, sclerotherapy or infrared coagulation, while higher grades (III–IV) more often need surgery such as hemorrhoidectomy or stapled hemorrhoidopexy. See our full comparison for details.

Sources & further reading

NHS — Haemorrhoids (Piles)
American Society of Colon and Rectal Surgeons (ASCRS) — Clinical Practice Guidelines for the Management of Hemorrhoids
NICE — Clinical Knowledge Summaries, Haemorrhoids
Cleveland Clinic — Hemorrhoids

Content last reviewed against the above sources: October 2026. This page describes general published guidance and does not replace an individual assessment by your doctor.

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