External haemorrhoids: symptoms and how to tell them from internal ones

2026-10-25

• Internal haemorrhoids sit inside the anal canal, usually do not hurt, but bleed bright red or prolapse.
• External haemorrhoids lie under the skin at the edge of the anus; you can feel them and they can be very painful.
• Sudden pain with a firm, bluish lump outside is often a sign of a thrombosed external haemorrhoid.
• A fissure, abscess or polyps can cause similar symptoms, so only a proctologist can make the diagnosis.
• Heavy bleeding, black stools, a high temperature or unbearable pain need urgent medical help.

You have noticed blood on the toilet paper or felt a small lump by your back passage, and you have started searching online for answers. Straight away you come across confusing terms: internal, external, mixed haemorrhoids. Which one do you have, and does it even matter?

It does matter, quite a lot: internal and external haemorrhoids have different symptoms, different complications and different approaches to treatment. Let's look at how haemorrhoids are arranged, what their signs are and why only a doctor can give the final answer to the question 'which type do I have?'

Where are haemorrhoids located? A little anatomy

Everyone has haemorrhoidal tissue: cushions of blood vessels that help keep the bowel contents in. Inside the anal canal runs the so-called dentate line, the border between the lining of the rectum and the skin.

• Internal haemorrhoids lie above this line and are covered by the bowel lining. It has almost no pain receptors, so internal haemorrhoids usually do not hurt.
• External haemorrhoids lie below the line, under the very sensitive skin around the anus. That is why any inflammation or clotting in them is felt sharply.
• Mixed haemorrhoids means both internal and external haemorrhoids are enlarged.

Internal haemorrhoids: how do they show themselves?

The most common sign is painless bright red bleeding at the end of a bowel movement: streaks on the paper, drops in the toilet or a stripe on the surface of the stool. Over time the haemorrhoids may grow and come out (prolapse). Doctors describe four grades:

• grade I: no prolapse, bleeding only;
• grade II: they come out when you strain and go back on their own;
• grade III: prolapsed haemorrhoids have to be pushed back with a finger;
• grade IV: they stay outside and cannot be pushed back.

Mucus discharge, itching, a feeling of dampness and incomplete emptying may also be troublesome. Pain with internal haemorrhoids usually appears when a prolapsed haemorrhoid becomes trapped and inflamed, which needs an urgent examination.

External haemorrhoids: symptoms and features

The typical symptoms of external haemorrhoids are soft, painless bumps at the edge of the anus that you can easily feel when washing. They swell after straining, long periods of sitting, heavy physical work and sometimes after spicy food or alcohol. They can make hygiene harder and cause itching and discomfort.

The main complication is thrombosis of an external haemorrhoid. A blood clot forms inside it, and within a few hours a firm, painful, bluish lump appears. The pain can be severe and make sitting and walking difficult; it is usually worst in the first few days and then gradually eases over one to two weeks. Sometimes the skin over the clot thins and a little dark blood comes out.

Once the clot has been absorbed, soft folds of skin, known as skin tags, often remain. They are harmless but can make hygiene harder; whether to remove them is up to your doctor.

How can you tell external haemorrhoids from internal ones?

Only an examination gives a definite answer, but some signs can point you in the right direction.

More likely internal if:

• the blood is bright red and appears painlessly at the end of a bowel movement;
• you cannot feel anything outside, or the lumps only come out when you strain;
• mucus, dampness or a feeling of incomplete emptying bother you.

More likely external if:

• you can feel soft or firm bumps at the edge of the anus;
• your main complaint is pain, itching or discomfort when sitting rather than bleeding;
• sudden sharp pain has appeared with a firm, bluish lump outside.

Many people have both internal and external haemorrhoids, so the signs can overlap. We have written more about the differences and mixed forms in our article on internal and external haemorrhoids.

Why do you need a proctologist?

Other conditions with completely different treatment can cause similar symptoms:

• anal fissure: sharp, cutting pain during and after a bowel movement, with a little blood;
• perianal abscess: throbbing pain that keeps getting worse, swelling, redness and a temperature;
• bowel polyps and tumours, which can also bleed;
• rectal prolapse, anal warts and skin conditions.

A proctologist will examine you, carry out a gentle finger examination and, if needed, anoscopy. If there are reasons to, such as being over 45, anaemia or a family history of bowel cancer, they will refer you for a colonoscopy. There is no need to feel embarrassed: for the doctor this is routine work, and the examination takes just a few minutes.

What can you do at home in the first few days?

While you wait for your appointment, simple measures can ease the discomfort:

1. Keep your stools soft: more vegetables, fruit, pulses and water, no straining and no long sessions on the toilet with your phone.
2. After the toilet, wash with cool or warm water and gently pat the skin dry, without rubbing or scented wipes.
3. Warm sitz baths for 10–15 minutes several times a day relieve pain and spasm.
4. For a swollen, painful external haemorrhoid, you can briefly apply something cold wrapped in cloth, for no more than 10 minutes at a time.
5. Do not sit on hard surfaces for long; get up and walk around often.

How are internal and external haemorrhoids treated?

According to international guidelines, the basis of treatment for any haemorrhoids is soft, regular bowel movements with enough fibre and water. Beyond that, the approach depends on the type and grade. Early internal haemorrhoids often respond to conservative treatment; if needed, the doctor may suggest minimally invasive procedures, and for large prolapsing haemorrhoids, surgery. For a thrombosed external haemorrhoid, in the first few days the doctor may offer to remove the clot under local anaesthetic; later, a conservative approach is usually chosen.

For the symptomatic treatment of acute haemorrhoids, your doctor may also recommend venotonic medicines. According to the instruction leaflet, Phlebodia 600 (diosmin 600 mg) is taken as 2–3 tablets a day with meals; if symptoms persist after several days of treatment, see a doctor. Details and contraindications are in the official instruction. Before use, read the instruction leaflet and consult a specialist.

The main points

Internal haemorrhoids tend to make themselves known through bleeding and prolapse, external ones through pain and bumps at the edge of the anus. These clues help you understand what is going on, but they do not replace an examination. A short visit to a proctologist will put an end to guesswork and worry, and treatment started early is usually simpler and easier.

Sources: 1. van Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis. 2020;22(6):650–662. 2. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284–292. 3. Instructions for medical use of Phlebodia 600 (Republic of Uzbekistan).

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