From the Guidelines
The main difference between external and internal hemorrhoids is their location, with external hemorrhoids developing under the skin around the anus and internal hemorrhoids forming inside the rectum. Hemorrhoids are swollen veins in the rectum and anus that can cause discomfort and bleeding. External hemorrhoids are visible as lumps or swellings and can be painful, especially when thrombosed, and may cause itching, irritation, and bleeding 1. Internal hemorrhoids, on the other hand, are typically not visible or painful because there are fewer pain-sensing nerves in this area, but they can bleed during bowel movements, producing bright red blood on toilet paper or in the toilet bowl 1. Internal hemorrhoids can sometimes prolapse, at which point they may become painful.
- The classification of internal hemorrhoids is based on the symptoms they cause, with first-degree hemorrhoids bleeding but not protruding, second-degree hemorrhoids protruding with defecation but reducing spontaneously, third-degree hemorrhoids protruding and requiring digital reduction, and fourth-degree hemorrhoids unable to be reduced 1.
- External hemorrhoids usually do not cause symptoms unless thrombosis occurs, in which case the patient experiences acute pain 1. Treatment options for both types include over-the-counter creams containing hydrocortisone or witch hazel for symptom relief, sitz baths, increased fiber intake, and adequate hydration 1. For persistent or severe hemorrhoids, medical procedures like rubber band ligation, sclerotherapy, or surgical removal may be necessary 1. The development of hemorrhoids is often related to straining during bowel movements, chronic constipation or diarrhea, obesity, pregnancy, or prolonged sitting, so addressing these underlying causes is important for prevention and management 1.
- According to the most recent study in 2021, flavonoids can be used to relieve symptoms of complicated hemorrhoids 1.
- It is also suggested to perform anoscopy as part of the physical examination for patients with complicated hemorrhoids, whenever feasible and well tolerated 1.
From the Research
Definition and Characteristics
- Hemorrhoids can be divided into two types: internal hemorrhoids and external hemorrhoids 2
- Internal hemorrhoids typically present with prolapse or painless rectal bleeding, while external hemorrhoids also bleed and can cause acute pain if thrombosed 3
Treatment Options
- External hemorrhoids usually require no specific treatment unless they become acutely thrombosed or cause patient discomfort 2
- Thrombosed external hemorrhoids can be treated conservatively or excised 3, 4
- Internal hemorrhoids can be treated with medication and non-operative measures, such as rubber band ligation and injection sclerotherapy, for low-graded cases 2
- Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred 2, 4
Comparison of Internal and External Hemorrhoids
- Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse, while external hemorrhoids are characterized by their location and presence of thrombosis 4
- Internal hemorrhoids are more likely to require surgical intervention, while external hemorrhoids can often be treated conservatively 2, 3
- Excisional hemorrhoidectomy is the mainstay operation for advanced internal hemorrhoids, while excision is the most effective treatment for thrombosed external hemorrhoids 5, 6