Internal vs External Hemorrhoids: The Difference

The question “internal vs external hemorrhoids” comes up constantly because the two behave so differently that people are often surprised they’re the same condition. The short version: it’s about location relative to the dentate line, the point inside the anal canal where the nerve supply changes from “barely feels anything” to “feels everything.”

Internal hemorrhoids

These form above the dentate line, inside the rectum, in an area with very few pain-sensing nerves. That’s why internal hemorrhoids are usually painless even when they bleed. The classic sign is bright red blood on the toilet paper or in the bowl, with no lump you can feel — at least at first. As they enlarge, internal hemorrhoids can prolapse, meaning they push down through the anus, which is when people start to feel something. Prolapse is graded I through IV depending on severity; see our full guide to hemorrhoid grades for what each stage looks like.

External hemorrhoids

These form under the skin around the anal opening, below the dentate line, in an area packed with pain nerves. That’s why external hemorrhoids are the ones people actually feel: itching, swelling, a lump you can touch, and pain — particularly if a clot forms inside one, which is called a thrombosed external hemorrhoid. That’s a hard, purplish, suddenly painful lump, and it’s a same-week problem worth seeing a doctor about rather than waiting out.

Side-by-side comparison

	Internal	External
Location	Inside the rectum	Under the skin, around the anus
Pain	Usually none, unless prolapsed	Common, especially if thrombosed
Bleeding	Bright red, painless	Possible, usually with pain
Visible lump	Only if prolapsed	Yes, often
Itching	Uncommon	Common
Typical first step	Fiber, fluids, less straining	Same, plus topical relief

Can you have both at once?

Yes — it’s common. A prolapsing internal hemorrhoid can drag tissue down and irritate the external area too, and someone with a low-fiber diet and a desk job is exposed to the same triggers regardless of which type ends up affected. Treatment overlaps heavily either way: fiber, hydration, less time straining on the toilet, and topical relief for external discomfort. We go through one structured version of that approach in our Hemorrhoids Healing Protocol review.

When the distinction actually changes treatment

For mild cases, it usually doesn’t — the conservative measures are the same. It matters more once a doctor is deciding between procedures: banding and sclerotherapy target internal hemorrhoids, while a thrombosed external hemorrhoid may need a small in-office incision if seen within the first couple of days of the clot forming. That’s a clinical decision, not a self-treatment one.

Frequently Asked Questions

Which type is more common?

Internal hemorrhoids are more commonly diagnosed, partly because they’re the ones that tend to bleed and get investigated, but many people have a mix of both without ever having either formally graded.

Can an internal hemorrhoid become external?

Not exactly — but a prolapsing internal hemorrhoid can protrude far enough to look and feel external, and a case can involve tissue on both sides of the dentate line at once.

Which one is more likely to need surgery?

Higher-grade internal hemorrhoids (III–IV) are the more common surgical candidates; see hemorrhoid surgery cost and recovery. Thrombosed external hemorrhoids sometimes need a minor procedure but rarely full surgery.

Do both types itch?

External hemorrhoids itch far more often, because the surrounding skin is irritated. Internal hemorrhoids don’t have the nerve density to produce that sensation.

What to Read Next

• What Are Hemorrhoids? Causes, Symptoms and Types
• Hemorrhoid Grades 1 to 4 Explained
• What Does a Hemorrhoid Look Like?