Internal vs External Hemorrhoids and How Each Is Treated
If you have seen blood after a bowel movement, or felt a sore lump near the anus, you may wonder what kind of hemorrhoid you have. Hemorrhoids are swollen veins. Where they form makes a big difference to how they feel. Internal hemorrhoids form in the lining of the anus and lower rectum. External hemorrhoids form under the skin around the anus.[1]
The difference between internal vs external hemorrhoids comes down to this: internal ones most often cause painless bleeding,[2] while external ones cause itching, tender lumps and soreness when you sit.[3] Each type suits a slightly different treatment. Through Starfish.com, a licensed clinician can review your symptoms and prescribe hemorrhoid treatment that fits where yours are.
Internal and External Hemorrhoids Side by Side
Find the symptoms that match yours, then read down the column to see which treatment usually fits.
| Internal hemorrhoids | External hemorrhoids | |
|---|---|---|
| Where they are | Inside, in the lining of the anus and lower rectum[1] | Outside, under the skin around the anus[1] |
| What you notice | Bright red blood on the stool, the toilet paper or in the bowl after a bowel movement[3] | One or more hard, tender lumps near the anus, and itching[3] |
| Pain | Usually painless, unless one slips out of the anus[3] | Ache or pain, especially when sitting.[3] Very painful if a blood clot forms[4] |
| Other signs | A hemorrhoid can slip out through the anus during a bowel movement[3] | A sudden, painful lump can mean a blood clot inside[4] |
| Treatment that usually fits | A hydrocortisone suppository works inside, where these hemorrhoids are | A cream with a numbing medicine and a steroid eases itching and pain on the outside[5] |
| If they keep coming back | In-office treatments, such as rubber band ligation, can help bleeding or slipping hemorrhoids[6] | Large external hemorrhoids that do not respond to treatment can be removed[6] |
Symptoms of Internal Hemorrhoids
Internal hemorrhoids most often show up as bleeding with a bowel movement, without pain.[2] The blood is bright red and appears on the stool, the toilet paper or in the bowl.[3] Sometimes an internal hemorrhoid slips down and out through the anus. This is called prolapse. Internal hemorrhoids that have not slipped out are most often painless.[3]
Symptoms of External Hemorrhoids
External hemorrhoids are under the skin, so you can often feel them as small, tender lumps. They can itch and ache, especially when you sit.[3] They are usually painless unless a blood clot forms or they become very swollen.[4]
Treatment for Internal or External Hemorrhoids
Describe where your symptoms are. A licensed clinician reviews your answers and decides whether the cream, the suppository or both suit you.
Which Treatment Fits Which Type
Our hemorrhoid treatment is a lidocaine-hydrocortisone rectal cream. It numbs the area and calms swelling to ease itching, pain and soreness.[5] You can also add a hydrocortisone suppository. It melts with body heat and lets the medicine out inside the rectum.[7] Here is how the two usually match each type:
- Mostly external symptoms such as itching and tender lumps usually suit the cream on its own.
- Mostly internal symptoms that have already been checked, such as discomfort inside, usually suit the suppository.
- Both at once is possible, and you can request the cream and the suppository together.
A licensed clinician reviews your answers and decides what fits. If treatment is right for you, the prescription goes to the pharmacy you chose. You pay for the medication at the pharmacy, the same way you would with a prescription from your own doctor.
Signs That Need Care Right Away
Most hemorrhoids can be treated simply. A few signs mean you need to be seen in person instead, and soon.
A sudden, very painful lump at the anus. This usually means a blood clot has formed in an external hemorrhoid, called a thrombosed hemorrhoid. The pain can build over the first 48 hours.[4] If it is severe, see a doctor in person promptly, because the clot may need to be removed with a small cut.[4]
Severe pain with bleeding from the rectum. The NIDDK advises seeking medical care right away.[6] Sometimes the muscles around the anus cut off the blood supply to an internal hemorrhoid. This is called a strangulated hemorrhoid.[1]
Heavy bleeding, or bleeding with dizziness, lightheadedness or fainting. Get medical help right away.[8]
Any new or changed bleeding. Bleeding from the rectum can come from other bowel conditions, such as Crohn’s disease or colorectal cancer, so the NIDDK advises having it checked by a doctor.[3] Most people with hemorrhoid symptoms do not have cancer, but bleeding from colon cancer is often mistaken for hemorrhoids.[2]
You are pregnant. We do not treat anyone who is pregnant, so speak to your obstetrician about these symptoms.
FAQ
How can I tell if a hemorrhoid is internal or external?
Where you notice it is the best clue. Bleeding without pain usually points to an internal hemorrhoid.[2] A lump you can feel around the anus, with itching or soreness, usually points to an external one.[3]
Are internal or external hemorrhoids worse?
Neither is always worse. Internal hemorrhoids can bleed and slip out,[3] while external ones are more often painful, especially if a clot forms.[4]
Can you have internal and external hemorrhoids at the same time?
Yes. That is why we offer the cream and the suppository together, so both can be treated at once.
Can Starfish.com treat both internal and external hemorrhoids?
Yes. Describe your symptoms in the questionnaire, and a licensed clinician decides whether the cream, the suppository or both fit. Some signs, such as a very painful lump or heavy bleeding, need an in-person visit instead.
Find the Hemorrhoid Treatment That Fits
Request the cream, the suppository or both, or let the clinician decide. Your prescription can be ready at your pharmacy within 1 to 2 hours.
References
- National Institute of Diabetes and Digestive and Kidney Diseases. “Definition & Facts of Hemorrhoids.” https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/definition-facts
- Arnold MJ, Smith D. “Management of Hemorrhoids: Guidelines From the ASCRS.” American Family Physician, 2025. https://www.aafp.org/pubs/afp/issues/2025/1200/practice-guidelines-hemorrhoids.html
- National Institute of Diabetes and Digestive and Kidney Diseases. “Symptoms & Causes of Hemorrhoids.” https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/symptoms-causes
- American Society of Colon and Rectal Surgeons. “Hemorrhoids.” Patient information. https://fascrs.org/patients/diseases-and-conditions/a-z/hemorrhoids
- U.S. National Library of Medicine, DailyMed. “Lidocaine hydrochloride and hydrocortisone acetate cream.” Human prescription drug label. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0cd1394d-e7b2-4e60-87ac-e12a0bda9d67
- National Institute of Diabetes and Digestive and Kidney Diseases. “Treatment of Hemorrhoids.” https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/treatment
- Apnar Pharma. “Hydrocortisone Acetate Suppositories 25 mg.” Prescribing information, via DrugCentral. https://drugcentral.org/label/cb60f2a6-8bab-c0f9-e053-2a95a90a422a/view
- U.S. National Library of Medicine, MedlinePlus. “Hemorrhoids.” Medical Encyclopedia. https://medlineplus.gov/ency/article/000292.htm
