Hemorrhoids are swollen vascular cushions in and around the anal canal, and what they look like depends entirely on which type you’re dealing with. External hemorrhoids sit just outside the anal opening and appear as soft, skin-colored or slightly bluish lumps you can feel or see with a mirror. Internal hemorrhoids originate inside the anal canal, above a boundary called the dentate line, and in their earliest stages are invisible from the outside. Internal hemorrhoids cause rectal bleeding, discomfort, and tissue prolapse, while external hemorrhoids cause pain particularly when they become engorged or thrombosed.
The Two Main Types and Where They Form
The distinction between internal and external hemorrhoids isn’t about severity. It’s about location. Internal hemorrhoids form above the dentate line, a ring of tissue roughly two centimeters inside the anal canal that separates two different types of lining. Because they sit above this line, in tissue that doesn’t have the same pain-sensing nerves as the skin around the anus, internal hemorrhoids often go unnoticed until they bleed or start to prolapse. External hemorrhoids form below the dentate line, in the area covered by regular skin. That skin has plenty of nerve endings, which is why external hemorrhoids tend to hurt in a way internal ones don’t.1JAMA. Hemorrhoidal Disease: A Review
Visually, an uncomplicated external hemorrhoid looks like a soft, rubbery lump or swelling at the edge of the anus. The color is usually close to your normal skin tone, though it can take on a slightly purple or bluish hue when blood pools inside. You might notice one distinct bump or several smaller ones clustered together. They’re often described as feeling like a grape or a small marble just under the skin. Some people have external hemorrhoids that come and go with bowel movements or straining, swelling up and then subsiding within hours or days.
Internal hemorrhoids are trickier to describe because in their early stage you simply can’t see them from the outside. What you notice instead are their effects: bright red blood on toilet paper, streaks of blood on the surface of stool, or dripping into the bowl. When internal hemorrhoids progress and begin to prolapse, you may see or feel tissue pushing out during a bowel movement. That tissue is typically moist, pink or reddish, and softer than the surrounding skin because it’s lined with the mucosal tissue from inside the anal canal rather than ordinary skin.
How Internal Hemorrhoids Progress Through Four Grades
Doctors classify internal hemorrhoids using a grading system based on how much the tissue protrudes from the anal canal. This matters for understanding what you might see and feel at different stages.
- Grade I: The hemorrhoid bleeds but doesn’t come out of the anal opening at all. You’ll see blood but never feel a lump.
- Grade II: The tissue pushes out during straining or a bowel movement but slides back inside on its own afterward. You might briefly see or feel something protruding, but it disappears without you doing anything.
- Grade III: The hemorrhoid prolapses and stays out until you gently push it back in with a finger. At this stage, you’re more likely to notice a persistent soft bulge.
- Grade IV: The tissue remains outside the anus and can’t be pushed back in. This stage can also include hemorrhoids that are thrombosed or incarcerated, meaning the blood supply is cut off.
One limitation of this grading system is that it focuses only on how far the tissue sticks out. It doesn’t capture how many hemorrhoidal columns are involved, how large each one is, or whether the prolapse is isolated to one spot or wraps around the full circumference of the canal.2ScienceDirect (Journal of Coloproctology). “PNR-Bleed” classification and Hemorrhoid Severity Score—a novel attempt at classifying the hemorrhoids So two people both labeled “grade III” can have very different-looking hemorrhoids, and that’s worth keeping in mind if you’re comparing your situation to a textbook description.
What a Thrombosed Hemorrhoid Looks Like
A thrombosed hemorrhoid is the version that usually sends people to the mirror in alarm. It occurs when a blood clot forms inside an external hemorrhoid, creating a firm, swollen lump that typically turns dark blue, purple, or nearly black. The lump appears suddenly, often overnight, and the pain is immediate and intense. Unlike an ordinary external hemorrhoid that may feel like a soft, squishy bump, a thrombosed one is hard and tender to the touch. The overlying skin may look stretched and shiny because of the swelling.
The size varies. Some thrombosed hemorrhoids are pea-sized, while others can grow as large as a walnut. If the pressure builds enough, the skin over the clot can erode and bleed, which paradoxically sometimes provides relief as the pressure decreases. Over the course of a few days to a couple of weeks, the clot gradually reabsorbs, and the lump softens and shrinks. The pain typically peaks in the first 48 to 72 hours and then slowly eases.
Once a thrombosed hemorrhoid resolves, it often leaves behind a deflated flap of excess skin called a skin tag. This is one of the more confusing aftereffects, because the skin tag itself is harmless but can look and feel like a new hemorrhoid to someone who isn’t sure what they’re looking at.
Skin Tags and Other Remnants
Perianal skin tags are soft, painless flaps of tissue around the anus. They’re extremely common after episodes of thrombosed hemorrhoids, and they can also develop from chronic swelling, inflammation, or after pregnancy. They don’t bleed, they don’t typically hurt, and they aren’t hemorrhoids in the active sense, though they may be cosmetically bothersome or cause minor hygiene challenges.
In a study of children and teenagers with external hemorrhoidal disease, about one in ten patients developed residual skin tags after their hemorrhoids resolved.3Europe PMC / Professional Medical Journal. External hemorrhoidal disease in child and teenage: Clinical presentations and risk factors The same phenomenon occurs in adults, often at higher rates because adult hemorrhoids tend to recur over longer periods. These tags can be a source of ongoing anxiety because they feel like lumps near the anus, but they’re just stretched-out skin left over after the swelling subsides.
Why Self-Diagnosis Goes Wrong So Often
Here’s where things get interesting and a little sobering. A study that reviewed nearly 500 patients referred to specialists with a diagnosis of hemorrhoids found that the diagnosis was correct only about two-thirds of the time. In the remaining cases, the actual problem turned out to be something else entirely. The most common misidentified conditions were anal fissures, skin tags, and hypertrophied anal papillae.4PubMed Central. Evaluating the Accuracy of Hemorrhoids: Comparison Among Specialties and Symptoms That’s a striking miss rate, and it wasn’t just patients getting it wrong. In roughly half the cases in the study, the referring clinician hadn’t even documented a physical examination of the anus.
The problem is that many anal conditions produce overlapping symptoms. Bleeding, pain, and a sensation of a lump near the anus are the main complaints that lead people to assume hemorrhoids, but those same symptoms show up in other conditions. If you’re relying on what you see in a mirror and a quick internet search, you’re working with limited information.
Conditions That Can Mimic Hemorrhoids
Several conditions either look like hemorrhoids or produce identical symptoms, and telling them apart matters because the treatments are different.
Anal Fissures
An anal fissure is a small tear in the lining of the anus. It causes sharp, burning pain during bowel movements and often produces bright red blood on toilet paper, which is exactly what many people experience with hemorrhoids. The key visual difference is that a fissure is a crack or split in the skin, not a lump. But fissures can also cause a small skin tag (called a sentinel pile) at the edge of the tear, which feels like a bump and adds to the confusion. In the diagnostic accuracy study mentioned above, anal fissures accounted for roughly a third of the incorrect hemorrhoid diagnoses.4PubMed Central. Evaluating the Accuracy of Hemorrhoids: Comparison Among Specialties and Symptoms
Anal Warts and Neoplasms
Anal warts caused by HPV can appear as flesh-colored, raised bumps around the anus that might be mistaken for external hemorrhoids, especially when small. More concerning, tissue removed during hemorrhoid procedures occasionally shows unexpected findings under the microscope. One review noted that about three percent of hemorrhoid specimens at one institution contained a form of squamous intraepithelial lesion, a precancerous change in the surface cells.5ScienceDirect (Human Pathology Reports). Review Challenging and newly emerging neoplastic diseases in anal canal and their mimics This doesn’t mean hemorrhoids turn into cancer. It means that lumps in that area deserve proper evaluation, because what looks like a straightforward hemorrhoid can occasionally harbor something that needs different attention.
Rectal Varices
In people with liver disease, dilated veins in the rectum called rectal varices can look similar to hemorrhoids but are a completely different condition. Rectal varices represent abnormal blood flow patterns caused by increased pressure in the portal venous system, and they account for a small fraction of variceal-related bleeding in Western populations.6Baishideng Publishing Group Inc. Rectal varices vs hemorrhoids-diagnosis and management They can occur in people with and without cirrhosis. The distinction matters because treating rectal varices like ordinary hemorrhoids, particularly with procedures like banding, can lead to dangerous bleeding. If you have known liver disease and notice rectal bleeding or lumps, this is worth mentioning to your doctor specifically.
Hemorrhoids During Pregnancy and After Birth
Pregnancy is one of the most common triggers for hemorrhoids, particularly in the second and third trimesters. The growing uterus puts increasing pressure on the pelvic veins, and the hormonal changes of pregnancy relax vein walls, both of which contribute to swollen hemorrhoidal tissue. Constipation, which is itself common in pregnancy, adds straining to the mix. The prevalence of symptomatic hemorrhoids is higher in pregnant women than in non-pregnant women, though exact rates are difficult to pin down because many cases go unreported.7PubMed Central. Constipation, haemorrhoids, and heartburn in pregnancy
What pregnancy-related hemorrhoids look like is no different from hemorrhoids in general: external lumps, possible prolapsing tissue, and the same bleeding patterns. But they tend to flare dramatically around delivery, especially after prolonged pushing during vaginal birth. The reassuring piece is that for most women, symptoms resolve on their own fairly soon after giving birth as the pressure on the pelvic veins decreases and hormonal levels return to normal.8Europe PMC. Hemorrhoids in pregnancy Skin tags may linger, but the active swelling and bleeding usually settle within weeks to a few months postpartum.
What a Clinical Exam Actually Involves
If you decide to see a doctor, knowing what to expect can take some of the anxiety out of the appointment. The evaluation typically starts with a visual inspection of the perianal area, where the doctor looks for external hemorrhoids, skin tags, fissures, or other abnormalities. A digital rectal exam follows, where the doctor inserts a gloved, lubricated finger into the anal canal to feel for internal hemorrhoids, masses, or areas of tenderness. An anoscopy, which involves inserting a short, hollow tube with a light, allows direct visualization of the lower rectum and is the best way to see internal hemorrhoids and assess their grade.9PubMed Central. Anorectal emergencies
The whole process takes a few minutes and, while uncomfortable, is not usually painful unless you have an active fissure or thrombosed hemorrhoid. Doctors sometimes recommend a colonoscopy as well, particularly if you’re over 45, have a family history of colorectal cancer, or if the bleeding pattern doesn’t quite fit what hemorrhoids typically produce. Rectal bleeding is overwhelmingly caused by benign conditions, but ruling out something more serious is straightforward and worth doing.
After Treatment and What to Expect Visually
If hemorrhoids are treated with a procedure like rubber band ligation, which is the most common office-based intervention for internal hemorrhoids, the tissue doesn’t disappear overnight. A small rubber band is placed around the base of the hemorrhoid, cutting off its blood supply. Over the next several days, the banded tissue shrinks and eventually falls off, usually without you noticing. You might see a small amount of bleeding when this happens. A comparison of rubber band ligation with an injection-based technique found that both approaches improved symptoms from baseline, though the injection group experienced less pain in the first week.10SpringerLink. Rubber band ligation or shaobei injection for the endoscopic treatment of symptomatic hemorrhoids? A retrospective study
After any hemorrhoid procedure, the area may look swollen and bruised for a week or two. Skin tags from prior episodes don’t go away on their own after treatment of active hemorrhoids; they require separate removal if they’re bothersome. The treated area generally returns to a normal appearance within a few weeks, though it’s common for some residual irregularity to remain that you can feel but that isn’t causing symptoms.
Blood Color as a Clue
One of the most useful visual signs is the color of any blood you see. Hemorrhoids typically produce bright red blood. It appears on the surface of the stool, on toilet paper, or dripping into the bowl. Because hemorrhoids involve superficial vessels close to the anal opening, the blood hasn’t had time to oxidize or mix with stool contents, so it stays vivid red.
Dark red, maroon, or black blood suggests the bleeding source is higher up in the digestive tract and warrants a different evaluation. Similarly, blood mixed thoroughly into the stool rather than coating its surface is less characteristic of hemorrhoids. These aren’t absolute rules, and even hemorrhoid bleeding can occasionally look different depending on how quickly you notice it, but the general pattern holds well enough to be a useful first-pass guide. When in doubt, having bleeding evaluated promptly is always reasonable, even if you’re fairly confident it’s hemorrhoids. The diagnostic accuracy data suggest that confidence, even from clinicians, is misplaced more often than you’d expect.