Are external hemorrhoids (hemorrhoids) typically tender?

From the Guidelines

External hemorrhoids are typically tender, especially when thrombosed, due to increased pressure and inflammation in the affected vein. This tenderness is a result of the sensitive nerve endings in the perianal skin becoming irritated by the swollen hemorrhoidal tissue, causing pain signals to be sent to the brain 1. The pain and tenderness associated with external hemorrhoids can be managed with over-the-counter pain relievers, witch hazel pads, cold compresses, warm sitz baths, and hemorrhoid creams containing hydrocortisone. Some key points to consider when managing external hemorrhoids include:

• The use of psyllium to reduce hemorrhoidal bleeding and painful defecation, as shown in one double-blind, placebo-controlled trial 1
• The potential benefits of controlling diarrhea with fiber, anti-motility agents, and specific treatment of any underlying cause to alleviate hemorrhoidal symptoms 1
• The limited data supporting the use of over-the-counter topical agents and suppositories, despite their widespread use in empirical treatment of hemorrhoidal symptoms 1
• The potential relief of pain due to thrombosed external hemorrhoids with nitroglycerin ointment, which decreases anal tone 1
• The importance of avoiding long-term use of high-potency corticosteroid creams, which can be deleterious 1.

From the Research

Characteristics of External Hemorrhoids

• External hemorrhoids can cause acute pain if thrombosed 2
• Thrombosed external hemorrhoids can be treated conservatively or excised 2, 3, 4
• External hemorrhoids usually require no specific treatment unless they become acutely thrombosed or cause patient discomfort 5

Symptoms of External Hemorrhoids

• External hemorrhoids can bleed and cause pain if thrombosed 2
• Bright red, painless rectal bleeding during defecation is the most common presentation of hemorrhoids in general, but this is more characteristic of internal hemorrhoids 4
• Acutely thrombosed external hemorrhoids are typically tender, but non-thrombosed external hemorrhoids are not usually characterized by tenderness 2, 4

Treatment of External Hemorrhoids

• Excision and evacuation of the clot is the optimal management for acutely thrombosed external hemorrhoids, ideally within 72 hours of symptom onset 4
• Incision and secondary excision can be used to treat thrombosed external hemorrhoids 3