Hemorrhoid symptoms and what each one means

Hemorrhoid symptoms depend on the type. Internal hemorrhoids, which sit in the lining of the anus and lower rectum, usually announce themselves with bright red blood or with tissue that slips out. External hemorrhoids, under the skin at the anal edge, are the ones that itch, ache, and leave a tender lump. A full picture of what hemorrhoids are helps, because the same word covers both.

A clot inside an external hemorrhoid is a third pattern. The lump shows up fast, feels firm, and can hurt a lot. The NIDDK’s page on hemorrhoid symptoms lists the usual clues for each type, and it also says rectal bleeding can come from other bowel diseases, including cancer of the colon or rectum.

The rest of this page is what each pattern tends to feel like, how doctors grade a hemorrhoid that slips out, and the other problems that copy these symptoms. A tear, an abscess, a fistula, itching from irritated skin, a leftover skin tag, a polyp, and colorectal cancer can all be mistaken for a hemorrhoid.

How internal and external hemorrhoids feel different

Hemorrhoids are swollen, displaced anal cushions, the pads of blood vessels and supporting tissue that line the anal canal ³. You have them even when you feel fine. They become a problem when they enlarge or slide downward. Sandler and Peery note that those cushions also help the anus stay closed ⁶.

Where they sit decides what you feel. Internal hemorrhoids are covered by lining that does not sense touch, pain, or temperature. External hemorrhoids are covered by ordinary skin, so they can ache ². A bleed from inside can be painless. A swollen lump on the outside often hurts when you sit ^1,4.

Internal hemorrhoid symptoms

The most common internal symptom is rectal bleeding with a bowel movement ³. The blood is bright red. You may see it on the stool, on the toilet paper, or in the bowl ¹. The ASCRS patient page on hemorrhoids says the bleeding can be brisk, dripping into the bowl, and that some people with internal hemorrhoids bleed very little or not at all.

Pain is the exception, until the tissue prolapses (slips through the anal opening). Internal hemorrhoids that stay inside most often do not hurt. Prolapsed ones can cause pain and discomfort ¹. Some people also notice mucus, a feeling that the bowel did not finish emptying, or itching ^2,4.

Doctors grade internal hemorrhoids by how far they slip, which also guides treatment. You can still have painless bleeding at any grade ⁴.

Grade 2 and grade 3 are the patterns people mean when they ask if they can push a hemorrhoid back in. Details of grades and which treatments fit each one are on the internal hemorrhoids page. Bleeding on its own, including what is typical and what is not, is covered under bleeding hemorrhoids.

External hemorrhoid symptoms

External hemorrhoids form under the skin around the anus ¹⁰. You may have anal itching, one or more hard tender lumps, and an ache or pain that is worse when you sit ¹. Between clots, people often describe intermittent swelling, pressure, and discomfort ².

Cleaning can be harder after a bowel movement, because the swelling changes the skin folds ¹⁴. Extra straining, rubbing, or scrubbing tends to make itching and soreness worse. For many people, external symptoms settle within a few days ¹. If a lump is still painful after that, or if it appeared suddenly and feels like a marble, read the next section before you wait it out. Day-to-day relief for this type is on the external hemorrhoids page.

What does a hemorrhoid look like?

Most people never see an internal hemorrhoid. It sits inside the anal canal, so the usual clue is blood rather than something you can spot ¹. A doctor sees it with a short lighted tube called an anoscope, where it looks like a bulge in the lining ^4,13.

What you might see or feel in a mirror depends on the type:

• A prolapsed internal hemorrhoid shows up as a soft bulge from the anus during or after a bowel movement. It is covered by moist lining rather than skin, and it may slip back in on its own or need a gentle push ^2,4.
• An external hemorrhoid is one or more lumps under the skin at the edge of the anus. They can feel hard and tender, and sitting often makes them ache ¹.
• A thrombosed hemorrhoid is a firm lump that is often bluish, because it holds a clot. It appears over hours and hurts constantly ².
• A skin tag is a soft, painless flap of skin that can stay after a swollen hemorrhoid goes down ¹⁰.

Looking is hard in this spot, and many other problems can look like a lump. A small tear, an abscess or a skin tag can all be mistaken for a hemorrhoid, so a mirror check is a starting point rather than a diagnosis. The section on look-alikes below covers the most common ones.

What a thrombosed hemorrhoid feels like

A thrombosed hemorrhoid is a blood clot in an external hemorrhoid. It is one of the complications NIDDK lists, along with skin tags, a sore that gets infected, strangulation, and anemia from ongoing blood loss ¹⁰.

The usual story is specific. A bluish lump appears just outside the anus, often after an unusual amount of straining. The skin there is tightly attached, so the clot raises pressure quickly. Pain is constant and can be severe. Sometimes the skin splits and clotted blood leaks out ². The pain often peaks about 48 to 72 hours after it starts and is largely easing after 4 to 5 days ².

Home care and removal do not follow the same clock. In a review of 231 people with a thrombosed external hemorrhoid, symptoms resolved in an average of 24 days with conservative care and in 3.9 days when the clot was excised. Most people treated without surgery did get better. Recurrence was less common after the clot was removed ⁷. Removal is worth a same-week visit if the pain is severe and the lump is only a few days old, because that is when excision helps most ⁴.

Why the symptom and the exam sometimes disagree

People often blame every anal complaint on hemorrhoids. The exam does not always agree.

In an Austrian screening study, 380 of 976 adults had hemorrhoids on colonoscopy. About 73% were grade 1, 18% grade 2, 8% grade 3, and under 1% grade 4. Of the people with hemorrhoids, 55% reported no symptoms at all ⁵. A 2019 review that rechecked what we know about hemorrhoids describes a German clinic study of 458 patients sent for abdominal or anal symptoms. Of the 63% who believed they had hemorrhoids, 18% actually had them when a short scope looked at the anal canal. Among people who did not think they had hemorrhoids, 13% did. Symptoms were similar in both groups ⁶.

If you want a first sort before you call, use the questions below or the full hemorrhoid symptom checker. It will not replace an exam.

Conditions that mimic hemorrhoids

The look-alikes below are the ones a first exam is meant to separate. A family physician review lays them out by the story and what the exam shows ⁴.

Anal fissure

An anal fissure is a small tear in the anus. The NHS page on anal fissure describes severe, sharp pain when you pass stool, then burning that can last for several hours, plus bright red blood on the paper or in the toilet. Hemorrhoids are on that same list of other causes of pain and bleeding, which is why the two get mixed up.

A fissure usually has no lump you can push back in. A hemorrhoid that only bleeds, without that tearing pain, is less likely to be a fissure. Constipation and frequent diarrhea raise the chance of a tear ⁸. Many fissures heal with softer stools and time. The NHS says to see a GP if symptoms are getting worse or there is no improvement after 7 days of self-care ⁸. A side-by-side comparison is on hemorrhoid or anal fissure.

Anal abscess and anal fistula

An abscess is a pocket of infection. Pain comes on gradually, and the exam shows a tender, fluctuant mass (a swelling that feels like it contains fluid) ⁴. Fever, feeling shivery, or pus are reasons to get help the same day. The NHS piles page says to ask for an urgent appointment if you feel hot, cold, or shivery and generally unwell, or if pus is leaking ¹⁵. A sitz bath will not treat a spreading infection.

A fistula is a small tunnel that can form after an abscess. The story is soiling and itching, and the exam may show a visible opening ⁴. It will not behave like a hemorrhoid that flares for a few days and then quiets down. Drainage that keeps coming back needs a surgeon, not another tube of cream.

Pruritus ani

Pruritus ani means itching around the anus. It is common, it has many causes, and anorectal problems are the ones found most often. A 2008 review noted that most treatment advice rests on low-level evidence, and that the practical plan is to stop irritants and stop scratching. Symptoms and skin changes often settle when that cycle breaks ⁹.

Hemorrhoids can be part of the itch, and so can leftover moisture, vigorous wiping, and scented paper. NIDDK notes that too much rubbing or cleaning makes hemorrhoid symptoms worse ¹. Pat dry. If you are wiping until the skin burns, switch to a gentle cleanser and read the notes on hemorrhoid wipes. Itch that wakes you up has its own pattern, covered in why hemorrhoids itch more at night.

Skin tags

A skin tag is extra skin. NIDDK describes it as what is left when a clot in an external hemorrhoid dissolves ¹⁰. The ASCRS account is the same: the clot stretches the skin, and the skin stays stretched after the body absorbs the clot. Some people have tags with no clot they can remember. Tags are covered with normal skin, they usually do not bleed, and they mostly need reassurance. Removal comes up when the tag makes cleaning difficult ^2,4.

A tag is soft and painless. A new, hard, tender lump is not a tag. Treat that as a thrombosed hemorrhoid or, if you also have fever, as a possible abscess.

Polyps and colorectal cancer

Polyps can cause painless bleeding and are found on endoscopy, not by feeling the outside of the anus ⁴. Cancer can cause pain, bleeding, a change in bowel movements, and weight loss, and the exam may show an ulcerating, firm lesion ⁴.

The American Cancer Society’s list of colorectal cancer symptoms includes a change in bowel habits that lasts more than a few days, a feeling that you still need to pass stool after you have gone, rectal bleeding with bright red blood, stool that looks dark brown or black, and weight loss you did not plan. The same page says infection, hemorrhoids, and irritable bowel syndrome can cause many of these symptoms, and that you should still see a doctor so the cause can be found. A closer look at the overlap, including studies of bleeding in adults under 50, is on hemorrhoids or colon cancer.

Typical hemorrhoid bleeding is a bright red streak and rarely causes anemia ⁴. Long-term blood loss can still lead to iron deficiency anemia, and heavy bleeding is uncommon but real ¹⁴. Dark stool, or bleeding with dizziness or feeling faint, is not a “wait and see” hemorrhoid symptom ^11,14.

The US Preventive Services Task Force recommendation on colorectal cancer screening advises screening for all adults age 45 to 75 at average risk. Adults 45 to 49 get a B recommendation, and adults 50 to 75 get an A recommendation ¹². Screening is for people without symptoms. Bleeding is a symptom, so it is a reason to be seen even if you are younger than 45. If you are due for screening, book that too.

NIDDK says to contact a doctor if symptoms are still there after 1 week of home care, and also if you have any bleeding from the rectum ¹. Fever, abdominal pain, and signs of anemia are red flags when someone has rectal bleeding ⁴. What happens in the room, and which clinician to book, is on when to see a doctor for hemorrhoids.

What the visit can and cannot tell from the story alone

A clinician can often diagnose external hemorrhoids by looking. Internal ones need a gloved finger exam and sometimes a short scope (anoscopy) to see the lining of the anus and lower rectum. The same visit is when they look for prolapsed tissue, a clot, leakage, irritated skin, tags, and a fissure ¹³. Colonoscopy or a flexible sigmoidoscopy is how they check the rest of the colon when bleeding might not be from a hemorrhoid ¹³.

While you wait for that visit, skip straining and long sits on the toilet, and ease up on wiping. Those habits make the symptoms you already have feel worse ¹. Causes of the pressure that starts a flare, and which of them the studies actually support, are on what causes hemorrhoids.