Hemorrhoids look different depending on their type and severity, but the most recognizable form is a soft, swollen lump near the opening of the anus that ranges in color from flesh-toned to bluish-purple. Internal hemorrhoids sit higher inside the anal canal and are usually invisible from the outside unless they have prolapsed, while external hemorrhoids form under the skin around the anus and are the ones you can actually see or feel. The appearance shifts considerably depending on whether a hemorrhoid is mildly swollen, thrombosed, or prolapsed, and understanding those visual differences matters because a few of the conditions that mimic hemorrhoids require very different treatment.
What External Hemorrhoids Look Like
External hemorrhoids develop beneath the skin surrounding the anal opening, below the anatomical boundary between the upper and lower anal canal known as the dentate line.1JAMA. Hemorrhoidal Disease: A Review When they flare up, they typically appear as one or more soft, rounded lumps or bulges right at the anal margin. The color is usually similar to the surrounding skin, though if the tissue is especially engorged, it may look slightly darker or have a purplish tint from the pooled blood beneath the surface.
In a mild case, you might notice nothing more than a subtle swelling that you feel in the shower rather than see in a mirror. As things worsen, the lump becomes more prominent, sometimes with a somewhat grape-like or pea-sized shape. The skin over an external hemorrhoid can appear stretched and shiny when the swelling is at its worst. If the hemorrhoid has been present for a while and has gone through repeated cycles of swelling and shrinking, the overlying skin can become slightly wrinkled or form a small flap, often called a skin tag, that persists even after the swelling resolves.
What Internal Hemorrhoids Look Like
Internal hemorrhoids originate above the dentate line, inside the anal canal, and are covered by the same type of moist tissue that lines the rest of the rectum.2PubMed Central. Hemorrhoids Because of their location, they are not visible from the outside in their earliest stage. Their main calling card at that point is painless bright red blood on toilet paper or in the bowl after a bowel movement, not something you can spot by looking.
Internal hemorrhoids become visible only when they prolapse, meaning they push through the anal opening. The tissue that protrudes is characteristically moist, pinkish-red, and has a soft, spongy texture that looks distinctly different from the dry skin around the anus. A useful visual marker is the presence of radial folds in the prolapsed tissue, ridges that fan outward from the center.3Surgical Clinics. Diagnosis and management of anorectal disease frequently seen in the emergency room Those folds are characteristic of internal hemorrhoidal tissue even when the hemorrhoid is not in distress, so they help distinguish a prolapsed internal hemorrhoid from other conditions.
How Doctors Grade Internal Hemorrhoids
Clinicians use a four-grade system that describes how much an internal hemorrhoid protrudes, and each grade has a different visual profile.
- Grade I: The hemorrhoid bulges into the anal canal but does not come out of the anus. You cannot see it externally. It is usually detected only during a clinical exam with an anoscope or during a colonoscopy.
- Grade II: The hemorrhoid pushes out of the anus during a bowel movement but slides back inside on its own afterward. You might catch a glimpse of moist, reddish tissue during straining that disappears within seconds.
- Grade III: The hemorrhoid protrudes and stays out until you manually push it back in. It appears as a soft, pinkish-red mass hanging from the anal opening.
- Grade IV: The hemorrhoid is permanently prolapsed and cannot be pushed back in. It stays visible as a protruding, often swollen mass of tissue outside the anus at all times.
This grading system is specifically about internal hemorrhoids.1JAMA. Hemorrhoidal Disease: A Review External hemorrhoids are not graded the same way because they already sit outside the anal canal by definition. The practical takeaway is that if you see something protruding only during or after a bowel movement, it is likely an internal hemorrhoid that has reached at least grade II.
Thrombosed Hemorrhoids and Their Distinct Appearance
A thrombosed hemorrhoid has a look that is hard to mistake for anything mild. It occurs when a blood clot forms inside a hemorrhoid, and the result is a firm, round lump that is typically dark blue, purple, or even black, depending on the amount and age of the clotted blood. The lump appears suddenly, within hours, and is usually quite tender to the touch. External hemorrhoids are the most common site for thrombosis because they sit under regular skin that contains pain-sensing nerve fibers, which is why a thrombosed external hemorrhoid tends to be intensely painful.
The size can range from a small marble to something closer to a large grape. The skin over it often looks taut and glossy. In some cases, the clot creates enough pressure to erode through the skin, causing dark red or brownish bleeding that looks different from the bright red blood typical of an internal hemorrhoid. Over the course of a few days, if left alone, the clot gradually breaks down and is reabsorbed; the lump shrinks, the color fades, and a residual skin tag may remain.
Internal hemorrhoids can also thrombose, though this is less common and more difficult to see. When it does happen, the prolapsed tissue often appears darker and more engorged than a typical prolapse. This is worth mentioning because the combination of prolapse and thrombosis tends to be more alarming to look at, but not every dark-colored prolapse is an emergency.
When the Appearance Signals an Emergency
Most hemorrhoids look unpleasant but are not dangerous. The exception is strangulation, which occurs when a prolapsed internal hemorrhoid gets trapped outside the anus and its blood supply is cut off. The tissue progresses from swollen and purple to a dusky, ischemic-looking color, and eventually to areas of mucosal sloughing, meaning the surface tissue begins to break down and die. This is the visual presentation associated with gangrenous hemorrhoids, and it requires emergency surgery to prevent serious infection in the pelvis.3Surgical Clinics. Diagnosis and management of anorectal disease frequently seen in the emergency room
If you see prolapsed tissue that is dark, firm, and shows patches of white, grey, or black discoloration, or if there is a foul smell, get to an emergency room. This is not a situation where watchful waiting or home remedies are appropriate. Strangulation is uncommon, but it represents the furthest extreme of what hemorrhoids can look like, and recognizing it early matters.
Skin Tags Left Behind
One of the most common sources of confusion is the residual skin tag. After a thrombosed external hemorrhoid heals or after repeated episodes of swelling, a small flap of excess skin often remains at the anal margin. These tags are flesh-colored, soft, and painless. They do not bleed, they do not swell, and they are not technically hemorrhoids anymore, even though they originated from one.
Skin tags are sometimes removed for cosmetic or hygiene reasons. In surgical settings, when surgeons excise redundant external hemorrhoidal tissue and skin tags, the goal is to restore a smoother contour around the anus.4Scientific Reports. Short-term and patient-reported outcomes of laser hemorrhoidoplasty plus excisional hemorrhoidectomy for the treatment of grade IV hemorrhoid But if a skin tag is not bothering you, there is no medical reason it needs to be removed. The important thing is knowing that a painless, non-bleeding skin flap is not an active hemorrhoid and does not need to be treated as one.
Signs You Cannot See
Not everything about hemorrhoids is visible. In fact, the most common symptom of internal hemorrhoids is bleeding, usually bright red blood noticed on toilet paper or in the toilet bowl, without any visible lump at all.5PubMed Central. Hemorrhoids: from basic pathophysiology to clinical management This is why relying solely on what you can see in a mirror will miss most early-stage internal hemorrhoids. Other symptoms that point toward hemorrhoids without necessarily producing a visible lump include:
- Itching: Mucus discharge from a prolapsing internal hemorrhoid can irritate the surrounding skin, causing persistent perianal itching even when no lump is apparent.
- Discomfort or fullness: A feeling of pressure or incomplete evacuation during bowel movements, sometimes described as a sensation that something is bulging inside the anal canal.
- Soiling: Minor mucus or fecal leakage, particularly with higher-grade internal hemorrhoids that prevent the anus from closing completely.
External hemorrhoids, when not thrombosed, may cause mild discomfort or a sensation of swelling without dramatic pain. The sharp, throbbing pain that people associate with hemorrhoids is most characteristic of thrombosis specifically.1JAMA. Hemorrhoidal Disease: A Review
What Hemorrhoids Can Be Confused With
Several conditions can produce lumps, bleeding, or pain in the same area, and some of them look strikingly similar to hemorrhoids at a glance. The most common source of confusion is an anal fissure, which is a small tear in the lining of the anus. Fissures cause sharp pain during bowel movements and bright red bleeding, just like hemorrhoids, but they do not produce a visible lump (though a sentinel skin tag at the edge of a chronic fissure can be mistaken for one).
An anal abscess appears as a firm, warm, reddened swelling near the anus, often with throbbing pain that worsens over hours regardless of bowel movements. Unlike a hemorrhoid, an abscess contains pus and typically requires drainage. Perianal warts caused by HPV can also produce bumps around the anus, but their texture is rough and cauliflower-like, distinct from the smooth, soft swelling of a hemorrhoid.
More rarely, rectal prolapse can be mistaken for a large prolapsed internal hemorrhoid. In rectal prolapse, the entire wall of the rectum protrudes, producing concentric circular folds rather than the radial folds characteristic of hemorrhoidal tissue. The distinction matters because rectal prolapse requires a different surgical approach. And while it is uncommon, anal cancer can present as a lump or bleeding at the anus. Any lump that is hard, fixed, irregularly shaped, or accompanied by unexplained weight loss warrants prompt medical evaluation regardless of whether you think it might be a hemorrhoid.
How a Doctor Confirms What You Are Seeing
A visual inspection of the perianal area is the first step, and it is often enough to identify external hemorrhoids, thrombosis, or prolapsed internal hemorrhoids. But for internal hemorrhoids that have not prolapsed, the standard diagnostic tool is an anoscope, a short, hollow, lighted tube inserted into the anal canal that lets the clinician directly visualize the hemorrhoidal cushions.6PubMed. The Evaluation and Office Management of Hemorrhoids for the Gastroenterologist The exam takes only a minute or two and, while not exactly comfortable, is considerably less involved than a full colonoscopy.
A digital rectal exam, where the doctor inserts a gloved finger, can detect masses but is actually not great at diagnosing hemorrhoids specifically, because hemorrhoidal cushions are soft and compressible under finger pressure. This is one reason that people sometimes receive reassurance from a basic exam only to continue having symptoms. If bleeding is the primary concern and the patient is over 45 or has risk factors for colorectal disease, a colonoscopy may be recommended, not because the hemorrhoid itself needs it but because rectal bleeding should not be assumed to come from hemorrhoids without ruling out other causes.
Why Hemorrhoids Change Appearance Over Time
Hemorrhoids are not static. The underlying tissue consists of vascular cushions with a rich blood supply, and the disease involves both dilation and distortion of those blood vessels along with weakening of the connective tissue that normally holds the cushions in place.5PubMed Central. Hemorrhoids: from basic pathophysiology to clinical management This means the same hemorrhoid can look different from one week to the next. It may swell noticeably after prolonged sitting or straining, then flatten and become nearly invisible after a few days of better habits. A thrombosed hemorrhoid that looked alarming on Monday may be half its original size by Friday as the clot dissolves.
This fluctuation is one reason people sometimes doubt whether they actually have hemorrhoids. They see a lump, it goes away, they assume it was something else, and then it returns. The cycle of engorgement and resolution is actually typical of the condition, and it reflects the dynamic nature of the vascular tissue involved. Over many years and many cycles, though, the supporting tissue can stretch permanently, which is why chronic hemorrhoids tend to worsen gradually, progressing from grade I to grade II or beyond, and why skin tags accumulate as the residual evidence of past flares.
Pregnancy and What to Expect Visually
Hemorrhoids during pregnancy deserve a separate mention because they are extremely common, and they often catch first-time expectant parents off guard. The combination of increased blood volume, hormonal changes that relax blood vessel walls, and the growing uterus pressing on pelvic veins creates near-perfect conditions for hemorrhoidal swelling. Constipation during pregnancy further increases the risk. Research on first-time pregnancies has found a strong link between pregnancy-related constipation and the development of external hemorrhoids and perianal complications.7Journal of Coloproctology. Hemorrhoids and related complications in primigravid pregnancy
Visually, pregnancy-related hemorrhoids look the same as any other external or prolapsed internal hemorrhoid, but they tend to appear more suddenly and become more prominent during the third trimester and especially after vaginal delivery. The pushing involved in labor can cause rapid engorgement or even thrombosis. The reassuring news is that many pregnancy-related hemorrhoids improve significantly in the weeks after delivery as pelvic pressure drops and blood volume normalizes. The skin tags, however, tend to stick around.
What Photos Online Actually Show You
If you have searched for hemorrhoid pictures, you have probably encountered a wide range of images, from mild swelling that looks like almost nothing to surgical photos that are genuinely alarming. It helps to know what you are looking at. Most clinical photographs of hemorrhoids are taken in a proctologist’s office or operating room under bright lighting with the patient in a position that maximally exposes the anal area. The resulting images can make even moderate hemorrhoids look dramatic simply because of the lighting, angle, and magnification.
Surgical textbook images, in particular, tend to show the worst-case scenarios: grade IV prolapse, strangulation, massive thrombosis. These cases exist, but they represent a small fraction of people with hemorrhoidal disease. The typical hemorrhoid that sends someone to the internet for reassurance is a small external swelling or a grade I to II internal hemorrhoid that bleeds a bit and resolves on its own. If the images you have found online look nothing like what you are experiencing, that is probably because your case is milder than the clinical extremes that tend to get photographed and published.
What matters more than matching your symptoms to a photo is paying attention to the characteristics that distinguish something benign from something that needs attention: a lump that is rock-hard rather than soft, bleeding that is dark rather than bright red, pain that escalates rather than resolves over a few days, or any change in bowel habits that accompanies the symptoms. Those features move the situation from “likely hemorrhoids” to “should be evaluated by a doctor,” regardless of how the lump compares to an image you found online.