Medically reviewed by: Yasir Gozu, MD, General Surgery Specialist
This article is for information purposes only; it is not a substitute for an examination and a physician’s assessment.
The difference comes down to location: internal hemorrhoids sit inside the canal, in an area with few pain nerves — which is why they bleed painlessly and prolapse. External hemorrhoids sit in the sensitive skin at the exit — they can be felt and they hurt, and if they clot they form a purple, firm swelling. The two often occur together. The treatment plan is built around this location distinction.
When I give the diagnosis at an examination, half my patients' first question is: "Is it internal or external?" It's a fair question, because these two words largely determine how the condition will behave and how it will be treated. The good news: you don't need a medical degree to understand the distinction — just one line.
The boundary line: a map of pain
Inside the anal canal there's a boundary invisible to the eye but very well known to the body (medically called the dentate line). Above this line is the bowel side: it is poor in pain nerves — you don't feel what's happening there, at most you notice the bleeding. Below the line is the skin side: rich in nerves, and it reports even the smallest event with pain. Internal hemorrhoids sit above the line, external hemorrhoids below it. Every difference in character stems from this single sentence.
Internal hemorrhoids: the silent bleeder
The typical story is painless, bright red bleeding — patients most often notice it on toilet paper for the first time. As they grow, they start to prolapse outward with straining: at first they go back in on their own (grade 2), then they need to be pushed back with a hand (grade 3), and eventually they stay out permanently (grade 4). Itching and a sensation of dampness can accompany this. Causing pain is the exception — if it hurts, either it has prolapsed and become trapped, or something else (like a fissure) is also present. I covered managing prolapse in this article.
External hemorrhoids: the noisy neighbor
Because it sits on the skin side, it announces itself with touch and pain. At rest it's a soft bump; its main event is the day a clot forms inside it — within hours a purple, firm, olive-like, very painful swelling appears. It looks frightening but isn't dangerous; it can be relieved instantly with a small procedure within the first 72 hours. Details of that window are in the external hemorrhoid article. There's also a leftover: small skin tags left behind once the clot resolves — harmless, and removed if you wish.
Side by side: one table
| Internal hemorrhoid | External hemorrhoid | |
|---|---|---|
| Location | Inside the canal (above the line) | Exit skin (below the line) |
| Pain | Typically none | Present; severe when clotted |
| Bleeding | Frequent, bright red | Less common |
| Palpable | Only when prolapsed | From the start |
| Typical crisis | Prolapse, entrapment | Clotting (thrombosis) |
| Treatment logic | Based on grade; laser is strong at grade 2-3 | Intervene in the acute phase; shrink if persistent |
What if I have both?
Very common — the cushion system is a single whole, and pressure strains both together. At examination we often see an "internal component + external component" together; we combine treatment into a single plan too: for example, during a laser session the internal cushions can be shrunk while the external prolapse is corrected at the same time. Don't try to guess which combination you have — that's a three-minute job for the examination.
Frequently asked questions
Does an internal hemorrhoid become external once it prolapses out?
No — a prolapsed internal hemorrhoid is still an internal hemorrhoid; its address is fixed from birth. To be "external" it would have to have originated on the skin side.
Which one is more dangerous?
Neither poses a life-threatening risk. The practical difference is this: the internal type silently advances through grades, while the external type causes noisy crises. Because it's easier to neglect the silent progressor, regular evaluation matters most there.
Does cream choice differ between internal and external?
Yes — suppositories target the internal area, creams the external area, and the choice of ingredients is made based on the presentation. Use beyond a week should always be a doctor's decision either way.
How are the two told apart during examination?
The external one is seen by inspection; the internal one is assessed in a few seconds with a small instrument (anoscope). It's a painless, no-preparation procedure.
Sources
- American Society of Colon and Rectal Surgeons (ASCRS), fascrs.org
- NHS — Piles (Haemorrhoids), nhs.uk
Let's pin down the address, and the plan follows on its own: 444 8 623 — Op. Dr. Yasir Gözü.
Yasir Gozu, MD
General Surgery Specialist
He has worked in anorectal diseases (proctology) for over twenty years, focusing on non-surgical laser treatments for hemorrhoids, anal fistula, anal fissure and pilonidal sinus. He sees patients at Avrupa Cerrahi in Besiktas Levent.
Content owner: Yasir Gozu, MD
Published: July 11, 2024
Last updated: July 8, 2026
