Haemorrhoids, Fissure, or Something Else? How to Tell the Difference

Why it matters

Haemorrhoids are the most common cause of rectal bleeding and perianal discomfort — but they're far from the only one. It's very common for people to assume it's haemorrhoids and put off getting it checked for months or even years. There are a few reasons why that delay matters:

• Conditions that look like haemorrhoids — such as an anal fissure — need completely different treatment, and treating the wrong thing won't help
• Rectal bleeding should always be assessed to make sure bowel cancer or polyps aren't the cause
• Most conditions in this area are very treatable when they're found promptly

This guide is here to help you understand the key differences between common perianal conditions — and to remind you that a proper examination is the only way to know for certain what you're dealing with.

Haemorrhoids (piles)

Haemorrhoids are enlarged blood vessel cushions in and around the anal canal. They're extremely common — roughly half of adults will have symptomatic haemorrhoids at some point in their life.

What to look for:

• Bright red blood on the toilet paper or in the toilet bowl — usually separate from the stool, not mixed through it
• Perianal discomfort, itching, or a sense of pressure
• A feeling of not fully emptying after a bowel motion
• A lump that comes down during or after a bowel motion (prolapse), in more advanced cases
• Little or no pain with internal haemorrhoids — because they sit above the dentate line, where the tissue has no pain sensation

There is one important exception: a thrombosed external haemorrhoid (where a blood clot forms inside an external haemorrhoid) causes sudden, severe pain and a very tender, firm lump near the anal opening.

Anal fissure

An anal fissure is a small tear in the lining of the anal canal — a bit like a paper cut in one of the most sensitive spots in the body. It's often confused with haemorrhoids because it also causes bleeding, but the experience is very different:

• Severe, sharp or burning pain during and after bowel movements — often lasting 30 minutes to hours afterwards
• The pain is typically much worse than any discomfort from haemorrhoids
• A small amount of bright red blood on the toilet paper — usually a smear rather than a significant bleed
• Dreading going to the toilet and putting it off because of the pain
• A small skin tag at the anal margin in chronic (long-standing) fissures

The key difference is pain. Internal haemorrhoids are generally painless; anal fissures are very painful. If pain is your main symptom, a fissure is the more likely cause.

Perianal abscess

A perianal abscess — a collection of pus near the anus — presents quite differently from haemorrhoids:

• Sudden onset of severe, constant pain around the anus — not related to bowel movements
• A tender, swollen, red lump near the anus that may feel warm to touch
• Often accompanied by a fever
• The pain doesn't ease between bowel motions — it's constant and gets progressively worse

This is a surgical emergency that needs prompt drainage. Please don't wait for a routine appointment — seek urgent medical attention. It's also worth knowing that around 30–50% of perianal abscesses will develop into an anal fistula (a persistent tunnel) after they're drained.

Anal fistula

An anal fistula is an abnormal tunnel that forms between the inside of the anal canal and the skin nearby. It presents as:

• A persistent or intermittent discharge (pus, blood, or mucous) from a small opening near the anus
• Recurrent abscesses forming in the same spot
• Ongoing perianal discomfort or the feeling of wetness

Unlike an abscess, an anal fistula isn't usually acutely painful — but it causes ongoing drainage and recurrent infection that won't resolve without treatment.

Colorectal cancer and polyps

Both colorectal cancer and bowel polyps can produce rectal bleeding that looks and feels identical to haemorrhoidal bleeding. You genuinely cannot tell the difference by sight alone.

Things that should prompt prompt assessment:

• Blood mixed through the stool, rather than just on the surface or paper
• A change in bowel habit lasting more than 4–6 weeks — looser stools, more frequent motions, or a feeling of incomplete emptying
• Unexplained weight loss or ongoing fatigue
• Iron deficiency anaemia found on a blood test
• Any symptoms if you're over 45, or if you have a family history of bowel cancer

The most important thing to take away here: having haemorrhoids doesn't rule out a more serious cause. Both can be present at the same time, and haemorrhoids can mask the symptoms of bowel cancer.

Quick symptom guide

Summary by symptom

• Blood on paper/pan, no pain — most likely internal haemorrhoids
• Severe pain with bowel motions + small amount of blood — most likely anal fissure
• Sudden painful swelling with fever — likely perianal abscess (urgent)
• Persistent discharge from perianal skin — likely anal fistula
• Blood mixed through stool / change in bowel habit — needs colonoscopy to exclude cancer

Frequently asked questions