Internal hemorrhoids sit inside the rectum where you can’t see or feel them in most cases, which makes checking for them tricky. Unlike external hemorrhoids that form visible lumps around the anus, internal hemorrhoids are often too soft for even a doctor to detect with a gloved finger during a standard rectal exam. The most reliable way to confirm them is through a quick in-office visual exam using a small lighted scope, but there are signs you can watch for at home that strongly suggest you’re dealing with one.
What You Can Check at Home
You can’t directly see or feel most internal hemorrhoids yourself, but you can track symptoms that point to them. The hallmark sign is bright red blood during or after a bowel movement. You might notice it on the toilet paper, dripping into the bowl, or coating the surface of your stool. This bleeding is typically painless, which is one of the key differences between internal hemorrhoids and other conditions.
If a hemorrhoid has grown large enough to push out through the anus (called prolapse), you may be able to feel or see soft, moist tissue protruding after a bowel movement. Early-stage prolapse slips back inside on its own. More advanced prolapse stays out unless you gently push it back in, and in the most severe cases it won’t go back in at all. A prolapsed internal hemorrhoid looks like a soft, pinkish or reddish bulge with folds that run in a radial pattern, like spokes on a wheel. That radial fold pattern distinguishes it from rectal prolapse, where the folds run in circular rings.
Other clues include a feeling of incomplete evacuation after a bowel movement, mucus discharge, or mild itching around the anus. Pain is not typical of uncomplicated internal hemorrhoids, so if your primary symptom is sharp or burning pain, something else may be going on.
How Doctors Diagnose Internal Hemorrhoids
Because internal hemorrhoids hide above the opening of the anal canal, a doctor needs to look inside with a lighted instrument. The most common tool is an anoscope: a short, hollow tube about three to four inches long that gives a direct view of the lower rectum. The exam takes only a few minutes and is done right in the office. For a broader look, a proctoscope or sigmoidoscope can examine a longer stretch of the lower colon.
During anoscopy, the doctor can see the hemorrhoids directly, assess their size, and determine their grade, which drives treatment decisions. There’s no special preparation required in most cases, though your provider may suggest emptying your bowels beforehand or using an enema depending on your situation. You should avoid anal medications or products before the exam so the tissue can be seen clearly.
The Four Grades of Internal Hemorrhoids
Doctors classify internal hemorrhoids on a scale of one to four based on how much they prolapse:
- Grade I: The hemorrhoid bleeds but stays inside the rectum. It appears as a small bulge on the rectal wall and is only visible during a scope exam.
- Grade II: The hemorrhoid pushes out during straining but slides back in on its own.
- Grade III: The hemorrhoid protrudes and needs to be manually pushed back inside.
- Grade IV: The hemorrhoid is permanently prolapsed and can’t be pushed back in. Thrombosed (clotted) hemorrhoids also fall into this category.
This grading system matters because grades I and II are typically managed with office-based treatments like rubber band ligation or infrared coagulation, while grades III and IV often require a surgical procedure. According to the 2024 guidelines from the American Society of Colorectal Surgeons, office treatments work well for lower grades, with surgery reserved for more advanced or treatment-resistant cases.
Ruling Out Other Conditions
Several conditions mimic internal hemorrhoids, and getting the right diagnosis matters. Anal fissures, which are small tears in the lining of the anus, cause bleeding and itching just like hemorrhoids. The key difference is pain: about 90% of fissures cause pain, while internal hemorrhoids usually don’t. Fissure pain also tends to come in sharp episodes, especially during bowel movements, rather than being constant.
Rectal polyps, inflammatory bowel disease, and in rare cases colorectal cancer can all cause rectal bleeding too. This is why doctors don’t just assume bleeding means hemorrhoids, particularly in people over 45 or those with additional symptoms.
When Rectal Bleeding Needs Urgent Attention
Most rectal bleeding from hemorrhoids is minor and resolves with basic care, but certain patterns warrant prompt medical evaluation. Be concerned if bleeding is accompanied by unexplained weight loss, a persistent change in bowel habits (new constipation, diarrhea, or narrower stools), or abdominal pain. In older adults especially, these combinations can signal a malignancy that needs to be ruled out.
If you notice a bluish-purple lump near the anus that is extremely painful, you likely have a thrombosed hemorrhoid, a blood clot inside the swollen vein. The pain peaks in the first 48 hours and can make sitting and walking miserable. Thrombosed hemorrhoids aren’t dangerous, but they sometimes become infected. Fever or chills alongside a painful lump are reasons to get medical attention quickly.
What to Expect at Your Appointment
If you decide to get checked, the visit is straightforward. You’ll typically lie on your side with your knees drawn toward your chest. The doctor first does a visual inspection of the outside of the anus, then gently inserts the anoscope. You may feel pressure or a brief urge to bear down, but the exam is not typically painful. The whole process takes a few minutes from start to finish.
If hemorrhoids are confirmed, treatment options are discussed on the spot based on the grade. Many people leave with a plan that involves dietary changes (more fiber, more water) and possibly a follow-up for an office procedure. For grade I hemorrhoids found incidentally, no treatment beyond lifestyle adjustments may be needed at all.