External vs Internal Haemorrhoids — What's the Difference?

Introduction

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 genuinely 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 extremely painful and need a different approach entirely. Understanding which type you have is the starting point for understanding your options.

What are internal and external haemorrhoids?

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.

Comparing symptoms side by side

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.

What is a thrombosed external haemorrhoid?

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 very 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 significant, and a surgeon can numb the area with local anaesthetic and remove the clot — which gives immediate, dramatic 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's been more than three days, warm sitz baths, pain relief, and time are usually the better path.

Causes

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 much 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.

When to worry

• 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

Treatment options

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 is the main workhorse treatment for Grade I–III haemorrhoids. It's done in the clinic without any anaesthetic and takes about ten minutes. Surgery (a haemorrhoidectomy) is reserved for Grade IV haemorrhoids or Grade III ones that haven't responded to banding.

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 — drainage alone has a high recurrence rate. 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 genuinely 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 significant problems, a formal surgical haemorrhoidectomy can address both simultaneously. Surgery is the most comprehensive option for complex or combined haemorrhoidal disease.

When surgery is needed

Surgery is recommended for Grade IV haemorrhoids, Grade III haemorrhoids that haven't responded to banding, large or painful external haemorrhoids, and combined internal-external disease that can't be adequately managed in a clinic. The recovery is real — most patients have significant discomfort for the first week, with warm sitz baths and regular pain relief making a big difference. Most people are back at a desk job within 2 weeks, and fully recovered by 4–6 weeks. The long-term outcomes are excellent and the recurrence rate is very low.

Frequently asked questions