External hemorrhoids are swollen veins that form just outside the opening of the anus, beneath the skin you can see and touch. Unlike internal hemorrhoids, which develop inside the rectum where you can’t feel them, external ones sit in an area rich with nerve endings, which is why they tend to be painful. They’re one of the most common causes of anal discomfort, and most people will deal with some form of hemorrhoid in their lifetime.
Where External Hemorrhoids Form
The anal canal has a dividing line called the dentate line. Above it, the tissue has few pain-sensing nerves. Below it, the skin (called anoderm) is loaded with nerve branches, making it highly sensitive to touch, pressure, and stretching. External hemorrhoids form below this line, which is exactly why they hurt so much more than internal ones. They develop when veins in this area swell and stretch under pressure, creating soft, visible lumps around the anus.
What They Look and Feel Like
You can usually see or feel external hemorrhoids yourself. Non-thrombosed ones (without a blood clot) tend to be the color of your surrounding skin, soft to the touch, and slightly raised. They can’t be pushed back inside because they don’t originate from inside the rectum.
Common symptoms include:
- Itchiness or irritation around the anus
- Hard or tender lumps near the anal opening
- Pain or aching that worsens when sitting
- Bleeding when wiping, usually small amounts of bright red blood
The discomfort often comes and goes. Sitting for long periods, having a bowel movement, or wiping too aggressively can all flare things up. Many people first notice them as a tender bump during a shower or after a particularly difficult bowel movement.
When a Blood Clot Forms
The most painful complication is a thrombosed external hemorrhoid, which happens when blood inside the swollen vein clots. The lump turns blue, black, or purple and becomes noticeably firmer. The pain is often sudden and intense, peaking within the first 48 hours. Sitting, walking, and using the bathroom can all feel excruciating during that window.
The good news is that most thrombosed hemorrhoids resolve on their own within a few weeks as the body gradually reabsorbs the clot. The bad news is that those first couple of days can be miserable. If the pain is severe and you’re still within that 48-to-72-hour window, a doctor can sometimes make a small incision to remove the clot, which provides near-immediate relief. After that window closes, the clot is already starting to break down and the procedure becomes less beneficial.
Once a thrombosed hemorrhoid heals, it sometimes leaves behind a small flap of stretched skin called an anal skin tag. These tags are harmless but can be mistaken for a new hemorrhoid, a wart, or another growth. Skin tags are flat, soft, and painless. Anal warts, by contrast, are caused by HPV, tend to start very small and grow, and often cause itching or burning.
What Causes Them
External hemorrhoids develop when pressure builds up in the veins around the anus, causing them to stretch and swell. Anything that increases pressure in your pelvic area or lower digestive tract raises your risk. The most common triggers are chronic constipation and straining during bowel movements. When you push hard to pass stool, you’re forcing blood into those anal veins and holding it there.
Pregnancy is another major cause, and for multiple reasons at once. The growing uterus puts direct pressure on pelvic veins, making it harder for blood to flow freely. Blood volume increases significantly during pregnancy, putting extra strain on veins throughout the body. On top of that, hormonal changes slow digestion, leading to constipation, which adds even more pressure. This is why hemorrhoids are especially common in the second and third trimesters.
Other contributing factors include sitting for prolonged periods (especially on the toilet), heavy lifting, obesity, a low-fiber diet, and chronic diarrhea. Aging also plays a role, as the connective tissue supporting veins around the anus weakens over time.
How They’re Diagnosed
A doctor can typically diagnose external hemorrhoids through a simple visual inspection of the area around the anus. They’ll look for lumps, swelling, skin tags, blood clots, and signs of irritation or fissures. A digital rectal exam, where the doctor inserts a gloved finger, helps check for tenderness, internal hemorrhoids, and muscle tone. No special imaging or lab work is usually needed for a straightforward case. The main reason doctors may want to do a more thorough exam is to rule out other causes of bleeding, particularly if you’re over 45 or have risk factors for colorectal conditions.
Managing Symptoms at Home
Most external hemorrhoids improve with conservative measures over a few days to a couple of weeks. The goal is to reduce swelling, ease pain, and soften stools so you’re not straining.
Warm sitz baths are one of the most reliable remedies. Sitting in a few inches of warm (not hot) water for 5 to 10 minutes, one to three times a day, increases blood flow to the area and relaxes the surrounding muscles. You can use a shallow basin that fits over your toilet seat or simply sit in the bathtub. Many people find the most relief by doing this after bowel movements.
Over-the-counter creams and ointments containing ingredients that numb the area or reduce inflammation can help with itching and pain. Witch hazel pads offer a cooling, soothing effect. Cold packs wrapped in a cloth and applied for 10 to 15 minutes can reduce swelling during a flare. Avoiding prolonged sitting, especially on hard surfaces, takes pressure off the affected veins.
When Surgery Becomes an Option
Most people never need surgery for external hemorrhoids. But when symptoms are severe, recurrent, or involve a large thrombosis, surgical excision is the most effective treatment. Office-based procedures like rubber band ligation and infrared coagulation, which work well for internal hemorrhoids, are generally not used for external ones because the area is too sensitive. Stapled hemorrhoidopexy, another common internal hemorrhoid procedure, is also not an option for external cases.
Surgical excision involves removing the entire hemorrhoidal sac. Recovery typically takes two to four weeks and can be uncomfortable, but it has the lowest recurrence rate of any treatment. It’s most commonly recommended for people with mixed hemorrhoids (both internal and external), large thrombosed hemorrhoids caught early, or hemorrhoids that keep coming back despite conservative care.
Preventing Recurrence
Since straining and hard stools are the primary drivers, fiber is your most important long-term tool. Current dietary guidelines recommend about 14 grams of fiber per 1,000 calories you eat, which works out to roughly 28 grams per day on a standard 2,000-calorie diet. Most people fall well short of that. Good sources include beans, lentils, whole grains, berries, pears, broccoli, and ground flaxseed. If you’re adding fiber to your diet, increase it gradually and drink plenty of water to avoid making constipation worse.
Staying hydrated keeps stools soft and easier to pass. Regular physical activity helps stimulate bowel function. Avoid sitting on the toilet longer than necessary, and resist the urge to scroll your phone while waiting. When you feel the urge to go, go promptly rather than holding it, which can dry out stool and make it harder to pass. These are small habits, but they address the root cause of most hemorrhoid flares.