The most telling signs of hemorrhoids are bright red blood on toilet paper after wiping, itching around your anus, or small lumps you can feel near your anal opening. Most people with hemorrhoids notice one or two of these symptoms rather than all of them, and the specific pattern depends on whether the hemorrhoid is inside the anal canal or on the outer surface.
Symptoms of Internal Hemorrhoids
Internal hemorrhoids form inside the anal canal, where there are fewer pain-sensing nerves. That’s why the most common sign is painless bleeding: you notice bright red blood on the toilet paper, on the surface of your stool, or dripping into the toilet bowl. There’s usually no pain, no lump you can feel, and no itching. Many people are surprised by the blood and assume something more serious is happening, but painless bright red bleeding during or after a bowel movement is the classic internal hemorrhoid pattern.
Internal hemorrhoids can grow large enough to slip outside the anus, which is called prolapse. When that happens, you may feel a soft, swollen lump protruding from the opening. Prolapsed hemorrhoids look like swollen red bumps, and they can bleed, cause discomfort, or produce a mucus discharge that irritates the surrounding skin. In mild cases, the tissue slides back in on its own after a bowel movement. In more advanced cases, you may need to push it back in with your finger, or it may stay outside permanently.
Symptoms of External Hemorrhoids
External hemorrhoids develop under the skin around the outside of the anus, where nerve endings are dense. They tend to be more uncomfortable than internal ones. The typical signs include:
- Hard lumps near the anus that feel sore or tender to the touch
- Itchiness or irritation around the anal area
- Pain or aching that gets worse when you sit
- Bleeding when you wipe
Sometimes you can see an external hemorrhoid in a mirror. It may appear as a small lump on the skin surface, and dilated veins underneath can give it a bluish tint. If a blood clot forms inside an external hemorrhoid (called a thrombosed hemorrhoid), the lump becomes firmer, turns a deeper blue or purple, and the pain intensifies significantly. Thrombosed hemorrhoids are one of the few types that cause sharp, constant pain rather than a dull ache.
What Causes Them
Hemorrhoids develop when pressure builds in the veins around the anus and rectum, causing them to stretch and swell. The most common trigger is straining during bowel movements, especially when stools are hard or you’re constipated. Sitting on the toilet for long periods (scrolling your phone, for example) also increases pressure on those veins. Other common contributors include chronic constipation or diarrhea, a low-fiber diet, heavy lifting, obesity, and prolonged sitting or standing throughout the day.
Pregnancy is another major trigger. About 30% to 40% of pregnant women develop hemorrhoids, most often in the third trimester, when the growing uterus puts increasing pressure on the pelvic veins. The straining involved in labor can also cause or worsen them. Eating 25 to 30 grams of fiber daily and avoiding long stretches of standing or sitting can help reduce that pressure.
How to Tell It’s Not Something Else
Several other conditions can mimic hemorrhoid symptoms, so it’s worth knowing the differences. The one most commonly confused with hemorrhoids is an anal fissure, which is a small tear in the skin of the anus. The key distinction is pain: fissures cause sharp, stinging pain during and after bowel movements, while most hemorrhoids cause little to no pain (unless they’re thrombosed). Fissures can also cause itching and bleeding, but the pain is typically more intense and persistent. You’re also more likely to feel a burning sensation that lingers.
An anal fistula is a small tunnel that forms between the inside of the anal canal and the skin nearby. Fistulas often produce pus or discharge along with pain, which hemorrhoids rarely do. Rectal polyps, abscesses, and in rare cases colorectal cancer can also cause rectal bleeding. This is one reason why new or persistent bleeding always warrants a proper evaluation, even if you’re fairly confident it’s hemorrhoids.
What Happens at a Doctor’s Visit
A doctor can often diagnose hemorrhoids quickly based on your symptoms and a visual exam. For external hemorrhoids, they’ll check the area around your anus for lumps, swelling, skin irritation, blood clots, or skin tags (small flaps of tissue left behind after a hemorrhoid heals). They’ll also look for signs of other conditions, like fissures.
For internal hemorrhoids, the process goes a step further. A digital rectal exam involves the doctor inserting a gloved, lubricated finger into the rectum to feel for swelling, tenderness, or lumps. If they need a closer look, they may use an anoscope, a short, lighted tube that lets them see the lining of the lower rectum directly. This is done in the office, takes just a few minutes, and typically doesn’t require any anesthesia. It’s not comfortable, but most people tolerate it well. Internal hemorrhoids are sometimes found incidentally during a routine colonoscopy performed for other reasons.
The Grading System for Internal Hemorrhoids
Doctors classify internal hemorrhoids into four grades based on how far they protrude from the anal canal. Grade I hemorrhoids bleed but don’t prolapse at all. Grade II hemorrhoids bulge out during a bowel movement but slide back in on their own. Grade III hemorrhoids prolapse and need to be manually pushed back in. Grade IV hemorrhoids are permanently prolapsed and can’t be pushed back inside. This grading matters because it determines treatment: lower grades respond well to dietary changes and over-the-counter remedies, while higher grades may need office procedures or surgery.
Red Flags With Rectal Bleeding
Most hemorrhoid bleeding is minor, a few streaks of bright red blood on the tissue. But rectal bleeding can occasionally signal something that needs urgent attention. If bleeding is continuous or heavy, or it’s accompanied by severe abdominal pain or cramping, go to an emergency room. Signs of shock from blood loss include rapid shallow breathing, dizziness when standing up, blurred vision, fainting, confusion, nausea, cold or clammy skin, and reduced urination. These require a 911 call.
For bleeding that’s mild but lasts more than a day or two, or if you notice a change in your stool color (dark, tarry, or maroon-colored stools suggest bleeding higher in the digestive tract), schedule an appointment with your doctor. Bright red blood from a known hemorrhoid that resolves within a day or two is generally not cause for alarm, but any new rectal bleeding deserves at least one proper evaluation to rule out other causes.