Are internal hemorrhoids (internal piles) typically painful?

Are Internal Hemorrhoids Painful?

Internal hemorrhoids are typically NOT painful unless thrombosis or complications occur. 1

Key Clinical Distinction

Internal hemorrhoids originate above the dentate line in tissue innervated by visceral nerves, which lack pain receptors. 2 This anatomical fact explains why:

• Uncomplicated internal hemorrhoids present with painless bright red rectal bleeding during defecation 1
• Prolapse, mucus discharge, and itching are common symptoms, but pain is absent 1
• The presence of significant anal pain suggests either thrombosis has occurred or an alternative diagnosis should be considered 2, 3

When Internal Hemorrhoids DO Cause Pain

Internal hemorrhoids become painful only in specific circumstances:

• Thrombosis of prolapsed internal hemorrhoids - when blood clots form in prolapsed tissue 2
• Strangulated grade IV hemorrhoids - when prolapsed tissue becomes incarcerated and ischemic 4
• Acute incarceration during pregnancy - approximately 0.2% of pregnant women require urgent hemorrhoidectomy for this complication 1

Contrast with External Hemorrhoids

External hemorrhoids are located below the dentate line and cause severe pain when thrombosed because this area has rich somatic innervation. 2, 5 This creates an important diagnostic distinction:

• External thrombosed hemorrhoids = acutely painful perianal lump 1
• Internal hemorrhoids = painless bleeding and possible prolapse 2, 3

Critical Clinical Pitfall

Up to 20% of patients with hemorrhoids have concomitant anal fissures, which ARE painful. 2, 3 Therefore:

• Do not automatically attribute anal pain to hemorrhoids 3
• Pain without visible thrombosis warrants investigation for fissures, abscesses, or other pathology 2, 5
• Perform anoscopy to visualize internal hemorrhoids and exclude alternative diagnoses 3

Grading System (Pain-Free Until Advanced)

Internal hemorrhoids are classified by prolapse severity, and pain is notably absent from this classification system: 2

• Grade I: Bleeding only, no prolapse
• Grade II: Prolapse with spontaneous reduction
• Grade III: Prolapse requiring manual reduction
• Grade IV: Irreducible prolapse (pain only if strangulation occurs)