External vs internal haemorrhoids — what is the difference?

When people say "haemorrhoids," they're usually talking about one condition — but there are actually two distinct types that are quite different from each other: internal haemorrhoids and external haemorrhoids. Some people have just one type; plenty of people have both at once, which is called combined haemorrhoidal disease.

The reason it matters which type you have is that the symptoms and treatments are different. Internal haemorrhoids are usually painless and respond well to a quick clinic procedure called rubber band ligation. External haemorrhoids — especially if a blood clot forms inside one — can be intensely painful and need a different approach entirely. Understanding which type you have is the starting point for understanding your options.

There's an important anatomical boundary inside the anal canal called the dentate line (or pectinate line). It's roughly halfway up the canal, and it separates two very different types of tissue. Above it, the lining is insensitive — there are no pain-sensing nerves there. Below it, the lining is essentially skin, with all of the pain nerves that skin normally has.

Internal haemorrhoids sit above the dentate line, in the insensitive zone. Because there are no pain fibres there, internal haemorrhoids are generally painless — even when they bleed. Pain only enters the picture if they prolapse (come down outside the canal) significantly, or if they get strangulated (their blood supply gets cut off).

External haemorrhoids sit below the dentate line, in the pain-sensitive zone. This is why they can hurt — and why a thrombosed external haemorrhoid (one with a blood clot inside it) can be excruciatingly painful. Even gentle cleaning of the area can be uncomfortable when external haemorrhoids are inflamed.

When someone says their haemorrhoids "hurt a lot," they almost certainly have an external haemorrhoid that has thrombosed. When someone says they're bleeding without pain, they almost certainly have internal haemorrhoids. Knowing this distinction takes a lot of the confusion out of what you're experiencing.

A thrombosed external haemorrhoid is one of the most common causes of sudden, severe pain in this area. A blood clot forms inside the haemorrhoidal tissue, which swells rapidly — sometimes to the size of a grape — and becomes intensely tender. The pain usually peaks within 24–48 hours, then gradually improves over 7–10 days as the clot dissolves and the swelling settles.

The best time to intervene surgically is within 72 hours of the pain starting. At that point, the clot is still soft, the pain is severe, and a surgeon can numb the area with local anaesthetic and remove the clot — which gives immediate, substantial relief. After 72 hours, the clot starts to harden and organise, and at that stage the natural resolution process is usually less painful than surgery. So if it has been more than three days, warm sitz baths, pain relief, and time are usually the better path.

Both types of haemorrhoids share the same common contributing factors:

• Low dietary fibre and hard stools — straining to pass firm stools is the main driver; soft stools are your best defence
• Prolonged sitting on the toilet — increases downward pressure on the anal cushions; a quick visit is better than lingering
• Pregnancy — increased pressure on pelvic veins and hormonal changes affect both types of haemorrhoids
• Chronic diarrhoea — repeated urgency and loose motions irritate and inflame the area
• Obesity — increases resting pressure in the anal canal
• Ageing — the connective tissue support naturally weakens over time, making prolapse more likely

External haemorrhoids are particularly prone to developing a clot (thrombosis) after heavy physical exertion, a bout of constipation, long-haul travel, or during pregnancy. Many people can pinpoint exactly what triggered their episode.

• Sudden severe pain with a new visible lump — get assessed promptly (this is likely a thrombosis)
• Any rectal bleeding that hasn't been properly assessed — bowel cancer needs to be excluded
• Prolapsed tissue that won't go back in, is changing colour, or is very painful — seek same-day assessment
• Symptoms that aren't improving after 4–6 weeks of conservative management
• Rectal bleeding if you're over 40 and haven't had a recent colonoscopy

Internal haemorrhoids

Treatment starts simple — dietary improvements, good hydration, avoiding straining — and steps up from there based on how severe your haemorrhoids are (graded I to IV). Rubber band ligation (banding) is the most common in-rooms treatment for Grade I–III haemorrhoids; it is done without any anaesthetic and takes about ten minutes. For Grade II–III haemorrhoids where banding has not worked or the haemorrhoids are bulkier, two day-surgery options sit between banding and excisional surgery: HALRAR (doppler-guided ligation with mucopexy) and Rafaelo (radiofrequency ablation). A formal haemorrhoidectomy is reserved for Grade IV haemorrhoids, or Grade III haemorrhoids that have not responded to the steps above.

External haemorrhoids — acute thrombosis

Within 72 hours of the pain starting: a surgeon can numb the area and remove the whole thrombosed haemorrhoid under local anaesthetic. The important thing is removing the whole haemorrhoid, not just draining the clot — in published series, drainage alone is followed by recurrence in around 25–40% of cases. Most patients feel substantially better within 24 hours.

After 72 hours: warm sitz baths 3–4 times a day, regular pain relief (paracetamol and/or ibuprofen), stool softeners, and a high-fibre diet. Most thromboses resolve naturally within 7–10 days, though a residual skin tag often remains after the swelling settles.

Skin tags

Skin tags near the anal opening are not haemorrhoids — they're the extra skin left behind after a thrombosed external haemorrhoid has resolved, or from tissue that was chronically stretched. They're not medically harmful, but they can cause hygiene difficulty, itching, or self-consciousness. Surgical removal under local or general anaesthetic is straightforward, though it's generally only recommended when symptoms are bothersome.

Combined internal and external disease

When you have both types at the same time, the internal component is usually addressed first — with banding if appropriate. If the external component is still causing substantial problems, a formal surgical haemorrhoidectomy can address both at the same operation. For complex or combined disease that is not adequately managed in clinic, surgery is generally the most comprehensive option.

Surgery is recommended for Grade IV haemorrhoids, Grade III haemorrhoids that have not responded to banding, large or painful external haemorrhoids, and combined internal–external disease that cannot be adequately managed in a clinic. The recovery is real — most patients have substantial discomfort for the first week, with warm sitz baths and regular pain relief making a meaningful difference. Most people are back at a desk job within 2 weeks, and fully recovered by 4–6 weeks. In published series, long-term outcomes are durable with low rates of recurrence.