Hemorrhoids: Internal vs. External and How to Treat Them

Most people don’t talk about hemorrhoids-until they have them. Then it’s all you can think about. The itching, the pain, the embarrassment. But here’s the truth: hemorrhoids are incredibly common. About 75% of people will deal with them at some point in their lives. And while they’re uncomfortable, they’re rarely dangerous. The real issue? Knowing whether you’re dealing with internal or external hemorrhoids-and what to do about it.

What Exactly Are Hemorrhoids?

Hemorrhoids aren’t some strange abnormality. They’re normal blood vessels in your rectum and anus that help control stool passage. Think of them like cushions. But when pressure builds up-from straining, pregnancy, sitting too long, or constipation-those cushions swell. That’s when they become a problem.

There are two main types: internal and external. They’re not just different in location-they’re different in how they feel, what they do, and how you treat them.

Internal Hemorrhoids: Silent But Not Harmless

Internal hemorrhoids form inside the rectum, above a line called the dentate line. This area has no pain nerves. So even when they swell, you often won’t feel pain. That’s why so many people don’t realize they have them until they see bright red blood on the toilet paper or in the bowl after a bowel movement.

Doctors grade internal hemorrhoids from I to IV:

• Grade I: Just swollen. May bleed, but don’t prolapse (protrude).
• Grade II: Protrude during straining but pop back in on their own.
• Grade III: Protrude and need to be pushed back in by hand.
• Grade IV: Stay outside permanently. Can’t be pushed back.

You might feel like you haven’t fully emptied your bowels. Or you notice a soft lump near the anus. But pain? Rare-unless it’s Grade III or IV and gets stuck outside. That’s when it can become painful and inflamed.

External Hemorrhoids: Pain You Can’t Ignore

External hemorrhoids form under the skin around the anus. This area is packed with pain nerves. So even a small swelling can feel like a throbbing, burning, or stabbing ache.

You’ll likely see a visible lump. It might be skin-colored and soft-or if a blood clot forms inside, it turns purple or blue and feels hard. That’s called a thrombosed external hemorrhoid. It’s the kind that makes sitting unbearable. You might feel it when you wipe, or even when you walk.

Unlike internal hemorrhoids, external ones rarely bleed unless they rupture. But the pain? It’s immediate and intense. Many people delay seeing a doctor because they think it’s just a pimple or an infected hair follicle. It’s not. It’s a swollen vein with a clot.

Can You Have Both at Once?

Yes. And it’s more common than you think. You might have a Grade II internal hemorrhoid that occasionally bleeds, and a small external one that itches constantly. The mix makes it hard to tell what’s causing what. That’s why self-diagnosis often goes wrong.

Many people assume any rectal bleeding is from hemorrhoids. But it could be an anal fissure (a small tear), Crohn’s disease, or even colorectal cancer. Fissures cause sharp, tearing pain during bowel movements-not the dull ache or itching of hemorrhoids. And while hemorrhoids might bleed without pain, fissures hurt without much bleeding.

If you’re unsure, don’t guess. See a doctor.

What Causes Hemorrhoids?

It’s not just “eating too little fiber.” Though that’s a big part. Here’s what actually pushes those veins to swell:

• Chronic constipation or diarrhea
• Straining during bowel movements
• Sitting for long periods-especially on the toilet
• Pregnancy (up to 35% of pregnant women get them)
• Obesity
• Heavy lifting
• Aging (tissues weaken over time)

Here’s something most people don’t know: Sitting on the toilet for more than 5 minutes increases pressure on your rectal veins by about 30%. That’s why scrolling on your phone while pooping is a bad habit. Use a small footstool to raise your knees above your hips. It helps your body relax naturally.

Home Treatments That Actually Work

For mild cases, you don’t need surgery. You need lifestyle changes.

• Eat 25-30 grams of fiber daily: Oats, beans, lentils, apples, pears, broccoli. If you can’t get enough from food, try psyllium husk (Metamucil). It’s cheap, effective, and gentle.
• Drink 8-10 glasses of water: Fiber pulls water into your stool. Without enough fluid, you’ll just get harder poop.
• Take sitz baths: Sit in warm (not hot) water for 15-20 minutes, 2-3 times a day. It reduces swelling and soothes irritation.
• Use witch hazel pads: They’re cooling and anti-inflammatory. No alcohol-based wipes-they dry out the skin.
• Try hydrocortisone cream (short-term): For itching and swelling. Don’t use it longer than a week without talking to a doctor.
• Avoid straining: If you don’t have a bowel movement in 5 minutes, get up. Try again later.

These steps fix the root cause: pressure and constipation. Most people see improvement in 3-7 days.

When You Need More Than Home Care

If home treatments don’t help after a week-or if you’re bleeding heavily, feeling dizzy, or the pain is getting worse-it’s time for medical help.

For internal hemorrhoids, doctors have three minimally invasive options:

• Rubber band ligation: A tiny band is placed around the base of the hemorrhoid. It cuts off blood flow. The hemorrhoid shrinks and falls off in 5-7 days. It’s 90% effective for Grades I-III. You’ll feel pressure or mild cramping for a day or two.
• Sclerotherapy: A chemical solution is injected into the hemorrhoid. It causes scarring and shrinkage. Less painful than banding, but slightly less effective.
• Infrared coagulation: A brief burst of heat seals off the blood vessels. Good for small hemorrhoids. Usually done in the doctor’s office with no downtime.

For thrombosed external hemorrhoids, the fastest relief is an incision. If you get one within 72 hours of the pain starting, the doctor can make a tiny cut, remove the clot, and relieve the pressure. It’s quick. It hurts for a minute. Then you feel amazing.

Surgery: Last Resort

If you have Grade IV hemorrhoids, recurrent problems, or failed other treatments, surgery might be needed.

• Hemorrhoidectomy: The hemorrhoid is completely removed. It’s the most effective option-95% success rate. But recovery takes 2-4 weeks. Pain is significant. You’ll need prescription painkillers.
• Stapled hemorrhoidopexy: The prolapsed tissue is pulled back up and stapled. Less pain than removal, but higher chance of recurrence. Not ideal for bleeding hemorrhoids.

Most people avoid surgery unless they have to. But if you’ve tried everything and still can’t sit comfortably or go to work, it’s worth considering.

What Doesn’t Work (And Why You Should Avoid It)

The internet is full of “miracle cures”: herbal creams, essential oils, tea tree oil, apple cider vinegar rinses. None of these have solid scientific backing. Some can burn your skin. Others just waste your money.

The American Society of Colon and Rectal Surgeons says: Stick to evidence-based treatments. That means fiber, water, sitz baths, and doctor-approved procedures-not Instagram hacks.

Prevention: The Real Long-Term Fix

Hemorrhoids come back if you don’t change your habits. Studies show:

• People who stick to high-fiber diets and drink enough water have only a 5-10% chance of recurrence.
• Those who go back to poor habits? Up to 50% get them again.

Make these part of your daily routine:

• Start your day with a glass of water and a high-fiber breakfast.
• Take a 10-minute walk after meals-it helps digestion.
• Don’t delay bowel movements. The longer you wait, the harder it gets.
• Use a footstool. It’s simple. It works.
• Stay active. Even light walking helps prevent constipation.

For pregnant women: Sleep on your left side. It takes pressure off the veins in your pelvis. Do pelvic floor exercises. They help support the area and reduce swelling.

When to See a Doctor

Don’t wait until it’s unbearable. Call a doctor if:

• Bleeding continues for more than a week
• You feel lightheaded or dizzy (sign of blood loss)
• Pain doesn’t improve after a week of home care
• You notice changes in bowel habits-like diarrhea or constipation that lasts
• You’re over 50 and have new rectal bleeding

Rectal bleeding is never normal. Hemorrhoids are common-but so are other things. Colon cancer can start with the same symptom. Don’t assume. Get checked.

Final Thought: It’s Not Just a Physical Problem

Hemorrhoids are embarrassing. That’s why so many people wait months before seeing a doctor. One survey found 68% of people delay care for over six months. But here’s the thing: doctors see this every day. They’ve seen it all. There’s no judgment. Getting help early means less pain, faster recovery, and no risk of complications.

Your body is telling you something. Listen. Eat more fiber. Drink more water. Move more. See a doctor if it doesn’t improve. You don’t have to live with this pain.