Prevention & care

Hemorrhoids: internal and external types, bleeding, and treatment choices

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Hemorrhoids, also called piles, involve enlarged or swollen vascular tissue around the anus and lower rectum. Internal hemorrhoids arise inside the lower rectum; external hemorrhoids occur under the skin around the anus. Location helps explain why bleeding, a lump, itching and pain do not always occur together.[1]

Location and complications are different descriptions

Location and complications are different descriptions
Term	What it describes	Typical distinction
Internal	Hemorrhoidal tissue inside the lower rectum.	Bleeding can occur without pain.[2]
External	Tissue under skin around the anus.	Itching, tenderness or a painful lump can occur.[1]
Prolapsed	Internal tissue protrudes through the anus.	A description of protrusion, not a separate external origin.[2]
Thrombosed external	A clot has formed in an external hemorrhoid.	Can cause a particularly painful swelling.[5]

Do not turn a common explanation into a diagnosis

Internal hemorrhoids can produce bright-red bleeding and prolapse; external hemorrhoids can cause discomfort or swelling. NIDDK also warns that rectal bleeding can come from inflammatory bowel disease or colorectal cancer. Knowing hemorrhoids are common does not rule out another cause of new or recurrent bleeding.[2]

Assessment includes symptom history and examination. A clinician may inspect the area, perform a rectal examination or use an instrument to examine the anal canal. Other investigations depend on the bleeding pattern and broader findings. The examination distinguishes hemorrhoids from problems such as an anal fissure or other lesions.[3]

Straining is relevant, but not the whole story

NIDDK lists straining, spending prolonged time on the toilet, chronic constipation or diarrhoea, pregnancy and age-related tissue changes among contributors. This is not a moral judgment about someone’s habits. Different contributors can overlap, and avoiding one does not guarantee that hemorrhoids will never occur.[2]

ASCRS describes a range of presentations, including prolapsed internal tissue and a thrombosed external lump. Severity and the predominant symptom affect the discussion of treatment. A painful external clot and painless internal bleeding are not interchangeable findings just because both use the same umbrella term.[5]

Conservative care, office procedures, and surgery

NIDDK describes fibre, appropriate fluid intake, avoiding straining and limiting prolonged toilet sitting as parts of conservative care. Medicines or topical products may help particular symptoms, but choosing them does not establish a diagnosis. Persistence or recurrence warrants reassessment rather than endlessly adding products to the same assumption.[4]

For selected internal hemorrhoids, clinicians can use rubber-band ligation, sclerotherapy or other office procedures. Surgery is considered for particular larger, prolapsing or persistent problems. Rubber-band ligation is a medical procedure for internal tissue; it is not a home method for tying off an unexplained anal lump.[4]

The decision considers symptoms, examination findings, previous treatment and recovery trade-offs. The patient resources cited here explain the options, but are not a complete independent comparison of every procedure’s recurrence and complication rates. The older NIDDK chapters should be read as foundational education rather than the latest surgical recommendation set.[5]

The word procedure does not describe one uniform treatment

The 2024 ASCRS guideline treats office procedures and surgical approaches separately. Rubber-band ligation is described as the most effective office treatment, while stapled hemorrhoidopexy is not routinely recommended as first-line surgery because efficacy and risks differ. A treatment suitable for selected internal hemorrhoids is not automatically appropriate for an external thrombosed lump or unexplained rectal bleeding.[6]

After banding, a change in symptoms can need a different response

After professional banding, mild aching, a temporary urge to pass stool and small bleeding can occur. The Gloucestershire Hospitals leaflet in England distinguishes these from increasing pain, swelling or discharge, difficulty passing urine, fever or feeling unwell: contact the treating service.[7]

Heavy bleeding that does not stop, or feeling unwell and feverish with severe pain, needs emergency assessment; tell the team about the banding. Ask how to contact the service and whether follow-up is planned. If you take medicine to prevent clots, ask the team for specific instructions.[7]

Evidence & uncertainty

Many symptoms improve with measures that reduce difficult stool passage and straining, while persistent or substantial problems may require an office procedure or surgery. A visible lump or bleeding does not establish that hemorrhoids are the cause. Assessment and treatment depend on the actual findings.[5]

Selected-source overview · Independent review pending

Published questions

Are internal and external hemorrhoids the same location?

Selected-source overview · Independent review pending. Read the evidence context.

No. Internal hemorrhoids arise inside the lower rectum; external hemorrhoids occur under the skin around the anus.[1]

Evidence behind this answer

Definition & Facts of Hemorrhoids
agency patient explanation · Date not stated
Selected relevant official page passages inspected · Internal and external locations and terminology