Hemorrhoid symptoms depend on where they form. Internal hemorrhoids, located inside the rectum, most often cause painless bleeding. External hemorrhoids, found under the skin around the anus, tend to cause itching, swelling, and a dull ache. Roughly one in four adults has hemorrhoids at any given time, making them one of the most common conditions people search for and one of the least talked about.
Internal Hemorrhoid Symptoms
Internal hemorrhoids sit inside the rectum where there are few pain-sensing nerves, so many people don’t even know they have them. The most common sign is bright red blood on the toilet paper, on the surface of your stool, or in the bowl after a bowel movement. The bleeding is typically painless and small in volume.
Internal hemorrhoids become more noticeable as they grow. Doctors grade them on a four-point scale based on how far they protrude:
- Grade I: No prolapse. You’ll only notice occasional bleeding.
- Grade II: The hemorrhoid pushes out during a bowel movement but slides back in on its own.
- Grade III: The hemorrhoid protrudes and must be pushed back in manually.
- Grade IV: The hemorrhoid stays outside the anus and can’t be pushed back in. At this stage, it can become extremely painful, especially if the blood supply gets cut off (a condition called strangulation).
If you feel tissue bulging from your anus during or after a bowel movement, that’s a prolapsed internal hemorrhoid. It may cause a feeling of pressure, mucus discharge, and irritation that wasn’t there when the hemorrhoid was fully internal.
External Hemorrhoid Symptoms
External hemorrhoids form under the skin around the anus, so you can often see or feel them. They typically appear as soft, skin-colored lumps. Unlike internal hemorrhoids, they commonly cause pain, especially when sitting. The key symptoms include:
- Itching or irritation around the anus
- A dull ache or pressure that can last throughout the day
- Tender lumps near the anus
- Bleeding when wiping
- Swelling around the anus
The discomfort from external hemorrhoids tends to be a continuous, throbbing sensation rather than a sharp, sudden pain. Sitting for long periods, lifting heavy objects, or straining on the toilet often makes it worse.
Thrombosed Hemorrhoids Feel Different
A thrombosed hemorrhoid is an external hemorrhoid where blood has pooled and formed a clot. It announces itself suddenly: you’ll feel a firm, painful lump near your anus, and it often appears blue, purple, or dark in color. The pain can be severe enough to make sitting or walking difficult.
Most people find the pain is worst in the first 48 hours. After that, the clot gradually breaks down and the swelling recedes over one to two weeks. In some cases a thrombosed hemorrhoid ruptures on its own, which releases the clot and causes a brief episode of bleeding but usually brings immediate pain relief. If the pain is unbearable in those first couple of days, a doctor can make a small incision to remove the clot in the office.
What Triggers Symptoms
Hemorrhoids develop when pressure builds in the veins around the anus and rectum. Constipation is one of the most common triggers because straining during a bowel movement forces blood into those veins and stretches the tissue. Sitting on the toilet for extended periods has the same effect, even if you’re not actively straining.
Pregnancy is another major contributor. Hormonal shifts slow digestion, making constipation more likely. The growing uterus puts direct pressure on pelvic veins, and blood volume increases significantly, all of which make the veins around the anus more likely to swell. Obesity, older age, a family history of hemorrhoids, and chronic conditions like diabetes and high blood pressure are also associated with a higher risk.
Hemorrhoids vs. Anal Fissures
Anal fissures are small tears in the lining of the anus, and they share enough symptoms with hemorrhoids to cause confusion. The biggest difference is the type of pain. Hemorrhoids produce a dull ache or pressure that can linger throughout the day. Fissures cause a sharp, tearing pain during a bowel movement, followed by a deep ache that lasts minutes to hours afterward.
Both conditions can cause bright red bleeding, but fissures don’t produce a visible or palpable lump. If you notice a soft swelling near the anus along with itching and pressure, hemorrhoids are more likely. If the main symptom is a stinging, knife-like pain during bowel movements with no lump, a fissure is the more probable cause.
Symptoms That Need Medical Attention
Rectal bleeding is the symptom that overlaps most with more serious conditions, including anal and colorectal cancer. A few features can help you tell the difference. Hemorrhoid bleeding is bright red, appears on the surface of stool or on toilet paper, and comes and goes with flare-ups. Blood that’s dark, mixed into the stool, or accompanied by unexplained weight loss, a persistent change in bowel habits, or swollen lymph nodes in the groin warrants prompt evaluation.
A lump near the anus that feels hard, irregular, or rough is also different from the soft, smooth swelling of a typical hemorrhoid. According to MD Anderson Cancer Center, any anal symptoms that last longer than two weeks, get progressively worse, or resolve and then return quickly should be evaluated by a doctor. This doesn’t mean the cause is cancer. It means the symptom pattern falls outside what hemorrhoids typically do.
How Hemorrhoids Are Diagnosed
A doctor can usually diagnose external hemorrhoids by visual exam alone. For internal hemorrhoids, the process starts with a digital rectal exam, in which the doctor inserts a gloved, lubricated finger into the anus to feel for swollen tissue. If more detail is needed, they’ll use an anoscope, a short, lighted tube inserted about two inches into the anus. The procedure takes a few minutes and can confirm the presence and grade of internal hemorrhoids, or identify other causes of bleeding like fissures or polyps.
For people over 45, or anyone with risk factors for colorectal cancer, a doctor may recommend a colonoscopy to rule out problems further up in the colon, especially if bleeding is the primary symptom and the cause isn’t obvious on anoscopy.