Hemorrhoid Symptoms and Diagnosis: Internal and External Hemorrhoids

Hemorrhoids occur when veins in the skin around the anus or in the lower rectum get swollen and inflamed. It’s not exactly clear what causes people to get hemorrhoids, but there are some common, accepted risk factors and conditions that lead to their development.

Aging can decrease muscle tone in the area, weakening the tissue and causing hemorrhoids to bulge, while obesity and pregnancy can increase the risk for hemorrhoids due to increased pressure on tissue in the area. (1)

Repeated straining to make a bowel movement, as well as constipation, are also associated with hemorrhoids.

Hemorrhoids are generally not dangerous or life-threatening, but they may be painful.

Common Hemorrhoid Symptoms to Watch For

The following signs and symptoms may indicate hemorrhoids:

• Bright red blood on toilet paper, in stool, or in the toilet bowl after a bowel movement
• Anal itching
• Pain around the anus, especially while sitting
• Pain during bowel movements
• One or more hard, painful lumps around the anus

If you have any symptoms of hemorrhoids, try to avoid excessive straining, rubbing, or cleaning around the anus.

Doing these things can make any irritation and itching worse, and can sometimes lead to bleeding.

Internal Hemorrhoids vs. External Hemorrhoids

There are two main types of hemorrhoids:

Internal Hemorrhoids These hemorrhoids develop inside the lower rectum. Internal hemorrhoids usually don’t hurt, but they often bleed painlessly, resulting in bright red blood you might notice when you go to the bathroom and wipe.

Most of the time, internal hemorrhoids are not visible to the naked eye. But in some cases, internal hemorrhoids may protrude through the anus, which is known as becoming prolapsed. When this happens, they will usually shrink back inside the rectum on their own. Protruding hemorrhoids can become irritated and itchy, and patients may find it difficult to clean themselves after a bowel movement.

Internal hemorrhoids are categorized by how prolapsed they are, which helps determine how they should be treated.

Grade 1 hemorrhoids means there is no prolapse. A prolapse that goes back in by itself is categorized as grade 2. Prolapse that needs to be pushed back in by the patient is considered grade 3. Grade 4 is when the prolapse can’t be pushed back in. (2)

External Hemorrhoids These hemorrhoids develop under the skin around the outside of the anus. They can be itchy or painful, and may feel lumpy.

External hemorrhoids are called thrombosed hemorrhoids when a blood clot develops within the hemorrhoid. The increased pressure can be very painful, especially within the first 48 hours after it develops. (1)

Thrombosed hemorrhoids tend to be bluish in color due to the clot. Sometimes the blood clot will go away on its own, but because the clot has stretched the skin, it may result in an anal skin tag — excess skin left when the blood clot in a thrombosed hemorrhoid is absorbed by the body. Skin tags do not require removal, but if it’s particularly bothersome to a patient, excision is an option. (1)

If a thrombosed hemorrhoid has been present for longer than two days, the pain has often peaked and you might try home treatments while waiting for the clot to clear up on its own. When the clot first forms, it can be very painful; if you make it to your doctor’s office during this time, an in-office surgical procedure, involving local anesthesia and excision of the hemorrhoidal tissue, may be available. (2)

RELATED: 8 Myths You’ve Been Told About Hemorrhoids

How Hemorrhoids Are Diagnosed by Your Doctor

See your doctor if you think you might have hemorrhoids, especially if you notice bleeding from your anus or rectum, or have bloody stools. Your doctor will want to rule out more serious problems that can cause bleeding from the anus or rectum, such as cancer.

Hemorrhoid symptoms may also be similar to those of other anal and rectal problems, including anal fissures, abscesses, warts, and polyps.

Your doctor will ask about your medical history and will ask you to describe your symptoms. Questions about your eating habits, toilet habits, and enema and laxative use are likely to come up. (3)

Your doctor will also perform a physical exam to look for lumps or swelling, prolapsed internal hemorrhoids, external hemorrhoids, skin irritation, skin tags, and anal fissures, which are small tears in the anus that can result in itching and bleeding. (3) This will involve a visual examination of the area.

Your doctor may also perform a rectal exam to diagnose internal hemorrhoids, check the muscle tone of your anus, and check for blood in the stool. This is done with a gloved, lubricated finger (called a digital rectal examination) and a tool called an anoscope.

An anoscope is a type of endoscope — a hollow, lighted tube that is inserted a few inches into the anus to help the doctor see any problems inside the lining of the rectum. This procedure is performed in the doctor’s office and doesn’t require anesthesia. (3)

Your doctor may also recommend additional tests to rule out other causes of bleeding, especially if you are over age 40.

These tests may include:

Colonoscopy After you’re sedated with medicine, your doctor uses a thin, flexible tube called a colonoscope to look at the inner lining of your colon.

A colonoscopy can help discover ulcers, polyps, tumors, and other areas of inflammation or bleeding.

Sigmoidoscopy This procedure is similar to a colonoscopy, but it uses a shorter tube called a sigmoidoscope to examine the lining of the rectum and the sigmoid colon (the lower part of the colon).

Barium Enema X-ray This is a special type of X-ray of the colon and rectum in which your doctor inserts a liquid solution containing barium sulfate into the rectum. The solution helps highlight specific areas in the colon for your doctor to examine in the X-ray images.

RELATED: 4 Signs Your Hemorrhoids Warrant a Doctor’s Visit

Additional reporting by Deborah Shapiro.