The most common sign of hemorrhoids is bright red blood on toilet paper or in the toilet bowl after a bowel movement. About 1 in 20 Americans have hemorrhoids, and roughly half of adults over 50 develop them. The signs you notice depend largely on whether the hemorrhoid is internal (inside the rectum) or external (under the skin around the anus), and whether a blood clot has formed.
Internal Hemorrhoid Signs
Internal hemorrhoids form inside the rectum, where there are fewer pain-sensing nerves. The hallmark sign is painless bleeding during bowel movements. You might see bright red streaks on toilet paper when you wipe, drops of blood in the toilet bowl, or blood coating the surface of your stool. The bleeding is typically small in volume and stops on its own.
As internal hemorrhoids progress, they can start to push through the anal opening. Doctors classify them in four grades based on how much tissue protrudes:
- Grade I: Bleeds but stays inside the rectum. No visible bulge from the outside.
- Grade II: Pushes out during a bowel movement but slides back in on its own.
- Grade III: Protrudes during bowel movements or straining and needs to be manually pushed back in.
- Grade IV: Stays outside the anus permanently and can’t be pushed back in.
When tissue protrudes, you may feel a soft, moist bulge at the anal opening, especially during or after a bowel movement. Internal hemorrhoids that prolapse can also leak mucus, which irritates the surrounding skin and creates a persistent itch or damp feeling.
External Hemorrhoid Signs
External hemorrhoids develop under the skin around the anus, where nerve endings are more concentrated. You can often feel or see them. A non-thrombosed external hemorrhoid is typically the color of your surrounding skin, soft to the touch, and sits just at the anal opening. Unlike internal hemorrhoids that prolapse, external hemorrhoids can’t be pushed back inside.
Common signs include a noticeable lump or swelling near the anus, itching, and mild discomfort, particularly when sitting or wiping. Bleeding can happen but is less characteristic than with internal hemorrhoids.
Signs of a Thrombosed Hemorrhoid
A thrombosed hemorrhoid occurs when a blood clot forms inside an external hemorrhoid. This is one of the more dramatic presentations and is hard to miss. The lump becomes hard, swollen, and often turns blue, purple, or dark in color. Pain can be intense, especially within the first 48 to 72 hours, and may worsen when you sit, walk, or have a bowel movement.
The pain typically peaks and then gradually improves over a week or two as the clot is reabsorbed. In some cases, the clot breaks through the skin on its own, causing a brief episode of bleeding that actually relieves the pressure. If the pain is severe and caught early, a doctor can remove the clot through a small incision, which provides faster relief.
Why Hemorrhoids Itch and Burn
Itching is one of the most bothersome hemorrhoid symptoms, and it has several overlapping causes. Swollen hemorrhoidal tissue irritates the sensitive skin around the anus directly. Internal hemorrhoids can leak small amounts of mucus that coat the perianal skin, creating a cycle of moisture, irritation, and itching. Incomplete cleaning after bowel movements compounds the problem, as does excessive wiping, which further damages already inflamed skin.
The moist environment around swollen hemorrhoids also encourages bacterial or fungal overgrowth, and tiny skin tears can develop that make the itching chronic. The urge to scratch feels overwhelming but makes things worse by further damaging the skin barrier.
Hemorrhoids vs. Anal Fissures
Anal fissures, which are small tears in the lining of the anus, share some symptoms with hemorrhoids, and the two are easy to confuse. The key difference is pain. Most hemorrhoids cause little to no pain unless they’re thrombosed. Anal fissures, on the other hand, cause sharp, stinging pain during bowel movements that can linger for minutes or hours afterward. Both can cause bright red bleeding and itching, but the pain pattern is the clearest way to tell them apart before seeing a doctor.
How Hemorrhoids Are Diagnosed
Diagnosis is usually straightforward. A doctor will ask about your symptoms, their duration, and risk factors like chronic constipation or straining. A visual inspection of the area can identify external hemorrhoids immediately.
For internal hemorrhoids, a digital rectal exam is the first step: a gloved, lubricated finger inserted into the anus to feel for swelling or other abnormalities. If more detail is needed, an anoscopy involves inserting a short, lighted tube about two inches into the anus to directly view the internal tissue. The procedure takes only a few minutes and doesn’t require sedation.
When Bleeding Needs Further Evaluation
Bright red rectal bleeding is common with hemorrhoids, but it also occurs with other conditions, including colorectal and anal cancers. Don’t assume rectal bleeding is from hemorrhoids, particularly if your bowel habits have changed, your stool looks different in color or consistency, or you’ve never been evaluated before.
If you experience large amounts of rectal bleeding, lightheadedness, dizziness, or faintness, that warrants emergency care. Hemorrhoids that don’t improve after a week of home care, or any episode of severe pain or heavy bleeding, should prompt a visit to your doctor sooner rather than later.