External vs Internal Hemorrhoids: Physical Exam and Treatment
Anatomical Definition and Classification
The fundamental distinction between internal and external hemorrhoids is their position relative to the dentate line—internal hemorrhoids originate above this line while external hemorrhoids arise below it. 1, 2
Physical Examination Findings
External Hemorrhoids
- Visible on external inspection of the perianal area without need for instrumentation 1, 3
- Present as a palpable perianal lump, particularly when thrombosed 1, 3
- Best visualized by everting the anal canal using opposing traction with the thumbs 1
- Skin tags may be evident on external examination 4
Internal Hemorrhoids
- Require anoscopy with adequate light source for proper visualization 4, 1
- Not visible on external examination unless prolapsed 1
- Classified by degree of prolapse:
Key Diagnostic Pitfall
Pain is the critical distinguishing feature—internal hemorrhoids are typically painless unless thrombosed, while external hemorrhoids cause significant pain when thrombosed due to somatic innervation below the dentate line 1, 3. If severe anal pain is present without visible thrombosed external hemorrhoid, consider alternative diagnoses such as anal fissure (present in up to 20% of hemorrhoid patients) or intersphincteric abscess 1, 3.
Clinical Presentation Differences
Internal Hemorrhoids
- Painless bright red rectal bleeding during defecation that drips or squirts into toilet bowl 4, 1
- Protrusion or prolapse of tissue 1
- Mucus discharge and secondary pruritus from soiling 1
- Pain only occurs with thrombosis 1
External Hemorrhoids
- Acute-onset anal pain with palpable lump when thrombosed 1, 3
- Otherwise asymptomatic unless skin tags interfere with hygiene 1, 3
- Bleeding only when local pressure causes skin erosion 1
Treatment Algorithm
Internal Hemorrhoids
Grade I-II (Non-prolapsing or Self-reducing):
- Increase dietary fiber and water intake 2
- Avoid straining during defecation 2
- Phlebotonics (e.g., flavonoids) reduce bleeding and pain, though 80% symptom recurrence occurs within 3-6 months after cessation 2
- Rubber band ligation is first-line procedural treatment if conservative measures fail—achieves 89% symptom resolution but requires repeat banding in up to 20% 2
- Infrared coagulation yields 70-80% success for bleeding and prolapse 2
- Sclerotherapy effective short-term in 70-85% but long-term remission only in one-third 2
Grade III-IV (Requiring Manual Reduction or Irreducible):
- Excisional hemorrhoidectomy is recommended for persistent symptoms despite office-based procedures 2
- Achieves low recurrence (2-10%) with 9-14 day recovery 2
- Also indicated for mixed internal/external disease 2
External Hemorrhoids
Asymptomatic or Mild:
Acutely Thrombosed (Presenting ≤72 Hours):
- Office-based excision under local anesthesia provides immediate pain relief and is superior to conservative management 1
- Use multiple counter-incisions rather than single long incisions to prevent step-off deformities 1
- Topical nifedipine 0.3% with lidocaine 1.5% every 12 hours achieves 92% resolution at 14 days versus 45.8% with lidocaine alone 1
Acutely Thrombosed (Presenting >72 Hours):
- Medical management is preferred as pain typically resolves spontaneously after 7-10 days 1, 2
- Stool softeners 2
- Oral analgesics (paracetamol or ibuprofen) 1
- Topical 5% lidocaine 2
- Short-term topical corticosteroids (maximum 7 days) to reduce inflammation 1
- Excision not required if symptoms resolving 1
Critical Caveats
Do not attribute all anorectal symptoms to hemorrhoids without proper examination—the American Gastroenterological Association emphasizes that other pathology is frequently overlooked when hemorrhoids are simply assumed 4. Perform anoscopy and flexible sigmoidoscopy for rectal bleeding, with complete colonoscopy indicated for atypical bleeding, no evident source, or significant colorectal cancer risk factors 4. Hemorrhoids alone do not cause positive fecal occult blood testing 4.