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Two kinds of piles, two different problems

Internal vs external piles, and how to tell which one you have.

Internal piles sit inside and usually bleed without pain. External piles sit under the skin at the opening, where you can feel them. Many people have both, and an examination tells you which.

Last updated 24 September 2026 · Based on Dr Sulaiman's published writing

Two diagrams of the back passage in cross-section: on the left, an internal pile above the dashed boundary line inside the canal; on the right, an external pile under the skin at the opening, below that line
  1. Internal pileInside, above the dashed line.
  2. External pileAt the opening, below the line.
01

Internal vs external piles at a glance

The typical pattern of each. These are patterns, not a way to diagnose yourself.

Based on Dr Sulaiman's published writing on piles.
Internal piles External piles
Where Inside the back passage Under the skin around the opening
Pain Usually none, unless they slip out and get irritated Often sore, swollen or itchy, especially when sitting
Bleeding Bright red blood on the paper or in the bowl, without pain Sometimes, if the skin is irritated
What you notice Blood, mucus, a lump that slips out with a motion, or a feeling of not having fully emptied A soft or tender lump you can feel at the opening
Graded? Yes, grades 1 to 4 by how far they come out No, they are described separately
02

Where internal vs external piles sit, and why only one usually hurts

Just inside the back passage there is a boundary where the lining changes to skin. That line explains almost everything about the difference.

Above the line, the lining is not pain-sensitive in the way skin is.

Internal piles start there, which is why they can bleed without hurting, and why a band can be placed on them in the clinic without an anaesthetic.

Below the line is ordinary, sensitive skin. External piles start there, so they are the ones you feel: sore when swollen, and very painful if a clot forms inside one.

A 2025 review in JAMA describes the same split, with internal piles above this line causing bleeding and prolapse, and external piles below it causing pain.

Two diagrams of the back passage in cross-section: on the left, normal small cushions of tissue on the inner wall; on the right, the same cushions swollen into piles
  1. Normal cushionsPart of everyone's anatomy.
  2. Swollen into pilesStraining and constipation make them swell.
Both kinds are normal blood vessels and tissue that have swollen. What differs is which side of the line they sit on.
03

What internal piles feel like

Often, very little. Many people find out from the paper, not from any pain.

a
Bleedingthe most common sign
Bright red blood on the tissue or in the toilet bowl after a motion, without pain. Common, and still worth having checked once, because other conditions bleed too.
b
Slipping outgrades 2 to 4
A soft lump that comes out with a motion. At grade 2 it goes back by itself, at grade 3 it needs pushing back, and at grade 4 it stays out. See piles grades 1 to 4.
c
Mucus and itchingwhen they come out
A pile that slips out can leave mucus, which irritates the skin and itches.
d
Not fully emptieda common complaint
A feeling that you have not quite finished, even after you have.
Internal piles seen through a scope turned back at the exit of the bowel: swollen, bluish cushions around the dark tube of the scope
Internal piles seen through a flexible scope turned back at the exit of the bowel. The dark tube is the scope itself. They sit above the line where the lining changes to skin, so they usually bleed rather than hurt. Photo: J. Guntau, Wikimedia Commons (file), CC BY-SA 3.0, cropped.
04

What external piles feel like, and why one can suddenly hurt

External piles are the ones people describe as sore, swollen or itchy, and the ones that make long hours at a desk uncomfortable.

You may feel a soft lump at the opening, with tenderness, itching or burning, and pain when sitting or passing a motion. If the skin gets irritated, it can bleed a little.

A man perched on the front edge of a chair, leaning onto one hip with a hand on the seat
Pain when sitting is typical of external piles, and long hours of sitting add pressure to the veins in the first place.

When a lump suddenly becomes very painful

A clot can form inside an external pile. It causes sudden, significant pain and a hard lump that can look bluish or purple. This needs prompt attention.

A 2025 review in JAMA reports that removing the clot within about 3 days of it forming eases the pain and makes another clot less likely.

After that, stool softeners and pain relief are the usual treatment.

A clotted external pile: a bluish-purple lump at the edge of the back passage, with a metal ruler beside it
A clotted external pile: the bluish-purple lump at the edge of the opening. A ruler sits beside it for scale. Photo: O. Gebbensleben, Y. Hilger and H. Rohde, from their 2009 study in BMC Research Notes, Wikimedia Commons (file), CC BY 2.0, cropped.
05

Can you have internal and external piles at the same time?

Yes, and it is common. Doctors call it mixed piles.

When both are present, treatment is planned around the whole picture rather than one pile.

Larger mixed piles, or external piles that are large or have clotted, are the situations where an excision operation is most often recommended.

Once an external pile settles, it can leave a soft fold of skin behind, called a skin tag. Skin tags do not bleed on their own and removal is optional.

How they differ from piles is covered at is it piles or something else.

Medical illustration of the back passage in cross-section, showing a swollen internal pile inside the canal and a swollen external pile under the skin at the opening
Internal and external piles together: one inside the canal, one under the skin at the opening.
06

How treatment differs for internal vs external piles

Internal piles have a range of treatments matched to the grade. External piles more often settle with care at home, unless they clot or keep flaring.

Usual pattern only. The examination decides what applies to you.
What you have Usual first step If that is not enough
Internal, grade 1 to 2 Fibre, water and toilet habits Rubber band ligation in the clinic
Internal, grade 2 to 3 Banding, or laser treatment if too large to band A stapled or excision operation, chosen by grade
Internal, grade 3 to 4 Piles surgery Planned at the consultation
External Care at home; surgery is rarely needed Excision if large or keeps flaring
External, clotted Prompt review; the clot may be removed within about 3 days Stool softeners and pain relief after that

For internal piles, banding resolves symptoms in 89% of patients in a 2025 JAMA review, although up to 20% need it again.

An excision operation brings recurrence down to 2 to 10%, at the cost of a longer recovery.

A 2021 meta-analysis of 8 randomised trials found the same trade-off: better control after surgery, less pain after banding.

Home care for both kinds is at treating piles at home.

07

Questions people ask about the two kinds of piles

Neither is dangerous in itself. External piles tend to hurt more; internal piles tend to bleed and, at higher grades, slip out. Which needs more treatment depends on size and grade, not on the name.

Sometimes you can feel an external pile, but an internal pile that slips out feels similar, and other conditions such as a fissure or skin tag can feel like both. An examination settles it in a few minutes.

Internal piles sit above the pain-sensitive line, so they can bleed without pain. That is typical of piles, but bleeding should still be examined once rather than assumed, because some other causes of bleeding do not hurt either.

No. A band only works on internal piles, above the sensitive skin. External piles are managed with home care, removal of a clot if one forms, or an operation if they are large.

Many settle with home care and time. A clotted one is very painful at first and worth having seen early. One that settles may leave a harmless skin tag behind.

Sources

  1. Ashburn JH. Hemorrhoidal disease: a review. JAMA, 2025. PubMed 40824576
  2. Dekker L, et al. Rubber band ligation versus haemorrhoidectomy for grade II to III haemorrhoids: a systematic review and meta-analysis of randomised controlled trials. Techniques in Coloproctology, 2021. PubMed 33683503

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