A Comprehensive Guide to Internal vs External Hemorrhoids

A Comprehensive Guide to Internal vs External Hemorrhoids

Hemorrhoids aren’t all the same. The two main categories are internal and external hemorrhoids.

They’re classified based on their location, but that’s not all that distinguishes them. Internal and external hemorrhoids may exhibit different symptoms, and they require different treatment approaches.

To help you learn more about the similarities and differences — and how they may affect your treatment options — check out this guide to internal vs external hemorrhoids.


While there are many internal vs external hemorrhoids differences, they both start the same way. The root issue with hemorrhoids is that veins in the rectal area become inflamed. They swell and bulge out.

Hemorrhoids can develop for a variety of reasons, but bathroom issues are a key source of the trouble. Straining on the toilet can be especially problematic. Chronic diarrhea may also lead to hemorrhoids. High body weight, heavy lifting, pregnancy and older age can contribute, too. The specific cause of a person’s hemorrhoids isn’t often clear, though.


The swollen veins don't always bulge out in the same place. Where the inflammation is located will determine whether you have internal or external hemorrhoids.

Internal hemorrhoids are located inside your body. They're found in the lower part of the rectum. Typically, they're not visible to you.

External hemorrhoids are on the outside. You'll find them around the opening to your anus. You may be able to feel them with your fingertips or use a mirror to look at them.

More specifically, the two types are differentiated based on what’s known as the dentate line — a tissue transition zone that’s about one-third of the way up the anal canal. Hemorrhoids above this line are considered internal, and hemorrhoids below it are external.


The lining of your rectum is a different type of material than the skin around your anus. Because of that, the covering of internal hemorrhoids is different from that of external ones.

Internal hemorrhoids are covered by rectal mucosa. That lining is similar to the tissue found throughout the rest of the digestive tract.

Because external hemorrhoids are located outside the rectum, they have a layer of skin over the top.


Internal and external hemorrhoids often present very differently.

The lining of your rectum isn’t very sensitive. Therefore, you might not feel internal hemorrhoids inside your body. The rectal lining is delicate, though, so internal hemorrhoids can bleed easily. Some people notice drops of blood in their toilet or on their toilet paper.

When it comes to the nerves around your anus, it’s a different story. The skin around the anal opening is quite sensitive. External hemorrhoids can hurt a lot. They may also feel itchy, irritated or uncomfortable.

The skin that covers them is tougher than rectal mucosa, so they bleed less easily than internal hemorrhoids. If you run your fingers over external hemorrhoids, they may feel like small bumps, lumps or swollen spots.


Internal hemorrhoids can prolapse. That means that they stick out of the anus. When that happens, you may be able to feel them with your fingers. They usually descend during a bowel movement.

Depending on their severity, they may retract on their own, or you may have to guide them back into place. The most advanced internal hemorrhoids stick out all the time.

External hemorrhoids can become thrombosed. A thrombus is a blood clot. If a clot forms inside your external hemorrhoid, you’ll probably notice it right away. Thrombosed hemorrhoids can be incredibly painful. They usually feel hard to the touch and may look blue or purple.


Some hemorrhoids clear up on their own. But if you do need treatment, the approach will depend on whether you have internal or external hemorrhoids.

Internal hemorrhoids that prolapse or cause other troubles may require some sort of surgical intervention. Some doctors perform hemorrhoidectomies to cut away the affected tissue. While effective, this procedure can involve a difficult recovery.

Hemorrhoid banding with a tool like the Adler Ligator (AL9000) offers a smart alternative for internal hemorrhoid treatment. Banding, a minimally invasaive procedure with an easy recovery time, restricts the blood flow to the hemorrhoid so that it will shrink and separate from the body.

Because external hemorrhoids are outside the body, you typically have better access to them for topical treatments. Sitting in a warm sitz bath or applying an ice pack can help you feel better. Over-the-counter hemorrhoid creams may relieve some of the irritation. Witch hazel, too, can help reduce swelling.

There aren’t as many surgical options for external hemorrhoids, though. Thrombosed hemorrhoids can be drained if you see the doctor right away. A hemorrhoidectomy is the primary option for surgically removing a chronic external hemorrhoid.

In some cases, patients have both internal and external hemorrhoids at the same time. Sometimes, fixing the internal ones helps clear up the external hemorrhoids as well. Undergoing a banding procedure for your internal hemorrhoids may help you fix the external ones without enduring a painful hemorrhoidectomy.

Internal vs External Hemorrhoids: Diagnosis and Treatment

For a quick review of the differences between internal vs external hemorrhoids, take a look at this video:

For an accurate assessment of your hemorrhoid situation, it’s a good idea to consult your doctor. A colorectal specialist can make a diagnosis and recommend a treatment plan.

Your physician may recommend hemorrhoid banding with the Adler Ligator. To find a specialist who uses this effective, affordable single-use instrument, visit our Find a Doctor page.

As with all medical issues, your physician is the ultimate source as to what procedure best fits your needs. Discuss all options and get a second opinion if you have any doubts. These articles are intended to be a source of general information only.

Brian Chandler