What are the differences in symptoms and treatment between internal and external hemorrhoids?

Symptom Differences Between Internal and External Hemorrhoids

Internal hemorrhoids primarily cause painless bright red rectal bleeding and tissue prolapse, while external hemorrhoids remain asymptomatic unless thrombosed, at which point they cause acute severe pain with a palpable perianal lump. 1, 2

Internal Hemorrhoid Symptoms

Internal hemorrhoids originate above the dentate line and present with a characteristic symptom pattern:

• Painless rectal bleeding is the hallmark symptom—blood is typically bright red, drips or splashes into the toilet bowl, and occurs during defecation 1, 2, 3
• Prolapse or protrusion of tissue through the anal canal, classified by severity:
  • Grade I: bleeding without prolapse 1, 2
  • Grade II: prolapse with spontaneous reduction 1, 2
  • Grade III: prolapse requiring manual reduction 1, 2
  • Grade IV: irreducible prolapse 1, 2
• Mucus discharge and staining leading to secondary perianal irritation and pruritus 2
• Generally painless unless thrombosis or strangulation occurs 1, 2

The absence of pain is explained by the visceral innervation above the dentate line, which lacks somatic pain fibers 2.

External Hemorrhoid Symptoms

External hemorrhoids arise below the dentate line and have a distinctly different presentation:

• Usually asymptomatic in their baseline state—they only become problematic under specific circumstances 1, 2, 4
• Acute severe pain when thrombosis occurs, caused by the rich somatic innervation below the dentate line 1, 2, 3
• Palpable perianal lump that appears suddenly with thrombosis 2, 3
• Occasional bleeding only when local pressure causes erosion through the overlying skin 2
• Hygiene difficulties when skin tags become large enough to interfere with proper cleaning 2, 4

Critical Diagnostic Distinctions

The presence of significant anal pain should immediately suggest either thrombosed external hemorrhoids or alternative pathology—not uncomplicated internal hemorrhoids. 2

Key examination findings:

• External hemorrhoids are visible on external perianal inspection 2, 4
• Internal hemorrhoids require anoscopy with adequate lighting for proper visualization 2
• Eversion of the anal canal by pulling with opposing thumbs helps identify external hemorrhoids and anal fissures 2

Important Clinical Pitfalls

Up to 20% of patients with hemorrhoids have concomitant anal fissures, which can also cause pain and bleeding 2. Do not automatically attribute all anorectal symptoms to hemorrhoids without thorough examination 2.

Severe anal pain without visible thrombosed external hemorrhoid may indicate:

• Anal fissure 2
• Small intersphincteric abscess 2
• Other anorectal pathology requiring different management 2

Any atypical features warrant colonoscopy, including dark blood, blood mixed with stool, guaiac-positive stools without visible source, anemia, or patient risk factors for colorectal cancer 1.

Treatment Implications Based on Symptoms

The symptom pattern directly determines treatment approach:

For symptomatic internal hemorrhoids:

• First-degree (bleeding only): fiber supplementation and increased water intake 1
• Second- and third-degree: office-based procedures like rubber band ligation (89% success rate) 1, 3
• Fourth-degree or failed conservative treatment: surgical hemorrhoidectomy 1, 3

For external hemorrhoids:

• Asymptomatic: no treatment needed 4
• Thrombosed within 72 hours: excision under local anesthesia for immediate relief 1, 2, 3
• Thrombosed after 72 hours: conservative management as pain typically resolves in 7-10 days 1, 2
• Topical nifedipine 0.3% with lidocaine 1.5% every 12 hours achieves 92% resolution at 14 days 2