Hemorrhoids: Internal vs. External and What Actually Works for Treatment

Most people think hemorrhoids are just a minor annoyance - something you get if you sit too long or eat too little fiber. But here’s the truth: hemorrhoids are a common, often misunderstood condition that affects about 75% of people at some point in their lives. And while they’re rarely dangerous, they can be incredibly painful, embarrassing, and disruptive. The real issue isn’t just having them - it’s not knowing whether you’re dealing with internal or external hemorrhoids, and what to do next.

What Exactly Are Hemorrhoids?

Hemorrhoids aren’t some weird abnormality. They’re normal blood vessels - vascular cushions - that help you control bowel movements. Think of them like shock absorbers inside your anus and lower rectum. But when pressure builds up - from straining, pregnancy, constipation, or sitting too long - these veins swell, stretch, and irritate. That’s when they become a problem.

There are two main types, and they’re not just different in location - they behave completely differently. The key difference? Pain.

Internal Hemorrhoids: Silent but Not Harmless

Internal hemorrhoids form inside the rectum, above a line called the dentate line. This area has no pain receptors, so even when they swell, you might not feel a thing. That’s why 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 on a scale of I to IV:

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

Grade I and II are common and often manageable at home. Grade III and IV? That’s when you need to see a doctor. Prolapsed hemorrhoids can get trapped outside, leading to swelling, clotting, or even tissue death - a medical emergency.

External Hemorrhoids: The Painful Ones

External hemorrhoids form under the skin around the anus. This area is packed with nerves - which is why even a small bump can feel like a knife stab. You’ll likely notice:

• A soft, skin-colored lump near the anus
• Itching or burning
• Pain when sitting or wiping
• Swelling that gets worse after bowel movements

The worst case? A thrombosed external hemorrhoid. This happens when a blood clot forms inside the swollen vein. It looks like a firm, purple or blue marble. The pain hits fast - often in the middle of the night - and makes sitting, walking, or even coughing unbearable.

Can You Have Both at Once?

Yes. And it’s more common than you think. Many people have a mix of internal and external hemorrhoids. That’s why symptoms can be confusing. You might have bleeding from inside (internal) and a painful lump outside (external). It’s easy to assume the pain is from the bleeding - but they’re two separate issues.

That’s also why self-diagnosis fails. A lot of people think every anal itch or bit of blood is hemorrhoids. But anal fissures - tiny tears in the lining - also cause bleeding and pain. The difference? Fissures hurt like a sharp tear during bowel movements. Hemorrhoids cause more of a dull ache, pressure, or constant itch.

What Causes Hemorrhoids?

It’s not just bad diet or sitting too long. Here’s what actually triggers them:

• Chronic constipation or diarrhea - both strain the rectal area
• Straining during bowel movements - even if it’s just a little
• Pregnancy - up to 35% of pregnant women get them, especially in the third trimester
• Obesity - extra weight increases pressure on pelvic veins
• Heavy lifting - especially with poor form
• Sitting for long periods - especially on the toilet

Here’s a simple trick that helps: put a small footstool under your feet while on the toilet. Raising your knees above your hips reduces rectal pressure by about 30%. It’s not magic - it’s anatomy.

Treatment: What Actually Works

The good news? Most hemorrhoids get better with simple changes - no surgery needed.

For Mild Cases: Home Care

• High-fiber diet: Aim for 25-30 grams of fiber daily. Think beans, oats, berries, broccoli, chia seeds. Most people get less than half that.
• Drink water: 8-10 glasses a day. Fiber without water just makes things worse.
• Sitz baths: Sit in warm (not hot) water for 15-20 minutes, 2-3 times a day. It reduces swelling and soothes irritation.
• Over-the-counter creams: Hydrocortisone cream for itching, witch hazel pads for inflammation. Avoid products with benzocaine or lidocaine long-term - they can irritate skin.
• Avoid straining: Don’t force a bowel movement. If it doesn’t come in 5 minutes, get up and try later.

For Internal Hemorrhoids: Minimally Invasive Procedures

If home care doesn’t work, doctors have tools that work fast and don’t require hospital stays:

• 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 a few days. It’s 90% effective for Grades I-III. You’ll feel pressure or mild cramping for 24-48 hours.
• Sclerotherapy: A chemical is injected into the hemorrhoid. It causes scarring and shrinkage. Less painful than bands, but slightly less effective.
• Infrared coagulation: Heat is applied to the tissue. It causes clotting and shrinkage. Good for smaller hemorrhoids.

For Thrombosed External Hemorrhoids

If you have a sudden, painful, purple lump - get seen within 72 hours. A simple procedure where the doctor makes a tiny cut and removes the clot can bring instant relief. Waiting longer means the clot hardens, and you’ll need to wait it out - which can take weeks.

Surgery: Last Resort

If hemorrhoids keep coming back, or you have Grade IV prolapse, surgery may be needed:

• Hemorrhoidectomy: The hemorrhoid is cut out. It’s the most effective - 95% success rate. But recovery takes 2-4 weeks. Pain is real. You’ll need prescription pain meds.
• Stapled hemorrhoidopexy: Used for prolapsed internal hemorrhoids. The surgeon staples the tissue back up. Less pain than removal, but higher chance of recurrence.

When to See a Doctor

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

• Bleeding lasts more than a week or gets worse
• Pain doesn’t improve after a week of home care
• You feel dizzy, weak, or lightheaded - signs of significant blood loss
• Your bowel habits change - constipation turns to diarrhea, or vice versa
• You’re over 50 and have new rectal bleeding

Rectal bleeding can be from hemorrhoids. But it can also be from colon cancer, IBD, or other serious conditions. Never assume it’s “just hemorrhoids.”

Prevention: Stop the Cycle

The biggest mistake? Treating the symptom, not the cause. Even after surgery or ligation, if you keep straining, sitting too long, or eating low-fiber food - they’ll come back. Studies show:

• People who stick to high fiber and hydration have only 5-10% recurrence
• Those who don’t? Up to 50% get them again

Make these habits non-negotiable:

• Start your day with a high-fiber breakfast - oatmeal with flaxseed and berries
• Keep a water bottle with you. Sip all day.
• Move regularly. Even a 10-minute walk after meals helps digestion.
• Don’t read on the toilet. Limit bathroom time to 5 minutes max.
• If you’re pregnant, sleep on your left side. It takes pressure off your pelvic veins.

What Doesn’t Work

There’s a flood of “miracle cures” online: herbal creams, essential oil blends, “natural hemorrhoid removal kits.” Most are scams. The American Gastroenterological Association warns against them. They don’t fix the root problem - and some can burn or irritate sensitive tissue.

And don’t rely on “just a little” bleeding. That’s your body’s warning sign. Ignore it, and it gets worse.

Final Thought

Hemorrhoids aren’t a sign of failure. They’re a sign your body’s under pressure - physically, diet-wise, or both. The solution isn’t a quick fix. It’s building habits that reduce strain, keep things moving, and protect your digestive health long-term. You don’t need to suffer in silence. Talk to a doctor. Change your routine. And remember - you’re not alone. Millions of people have been where you are. And most of them got better.