Here’s something that confuses many people: one person with piles bleeds every day but feels no pain, while another feels a painful lump yet barely bleeds. Both have piles. The difference comes down to one line inside your body.
The line that changes everything
Inside your anal canal there is a boundary called the dentate line. Above it, the lining has very few pain nerves. Below it, the skin is full of them, just like the skin on your fingertips.
- Piles above this line are internal piles.
- Piles below it are external piles.
That single fact explains why internal piles are usually painless and external piles can hurt a lot. (New to the topic? Start with what piles is.)
Internal piles
- Form inside the rectum, usually can’t be seen or felt at first
- Main sign: painless, bright red bleeding while passing stool
- May slip out (prolapse) during straining
- Can leave a mucus discharge and itching
The 4 grades of internal piles
| Grade | What happens | Usual approach |
|---|---|---|
| 1 | Bleeds but stays inside | Diet, fibre, habits |
| 2 | Comes out while straining, goes back by itself | Diet plus office procedures if needed |
| 3 | Comes out and must be pushed back by hand | Procedures such as banding; sometimes surgery |
| 4 | Stays outside, can’t be pushed back | Usually surgery |
Grades help doctors decide treatment. We cover this in does every case of piles need an operation?
External piles
- Form under the skin around the anus
- Feel like a soft or firm lump at the edge of the anus
- Cause itching, irritation and pain, especially while sitting
- Make cleaning after a bowel movement harder
If blood clots inside an external pile, it becomes a thrombosed pile: suddenly very painful, hard and bluish. Read what a thrombosed pile feels like.
Side-by-side
| Internal piles | External piles | |
|---|---|---|
| Location | Inside, above the dentate line | Outside, under anal skin |
| Pain | Usually none | Often painful |
| Bleeding | Common, bright red | Less common |
| Can you feel it? | Only if it prolapses | Yes, as a lump |
| Itching | Sometimes, from mucus | Common |
External piles treatment at home
- Warm sitz baths 2 to 3 times a day
- Keep the area clean and dry; pat, don’t rub
- Soft stool with fibre, water and isabgol
- Avoid long sitting; use a soft cushion if needed
- Soothing creams can ease itching for a few days
Can you have both?
Yes, and it’s common. They’re called mixed piles, and both are caused by the same pressure from straining and long toilet sitting. Interestingly, “hemorrhoids” and “piles” are just two names for the same thing. Read hemorrhoids vs piles.
Frequently Asked Questions
Which is worse, internal or external piles?
Neither is always worse. Internal piles bleed more, while external piles hurt more. Grade 3 or 4 internal piles and clotted external piles usually need medical care.
Do internal piles hurt?
Usually not, because there are few pain nerves inside. They may hurt if they prolapse and get trapped outside.
Can external piles go back inside?
No. External piles form outside the anal canal, so they don’t go back in. A prolapsed internal pile can, which is different.
How long do external piles last?
Mild external piles usually settle in a few days to two weeks with home care. A clotted one may take two to three weeks.
Can internal piles become external?
They don’t change type, but a large internal pile can prolapse and look like an external lump.
About the author: Deepak Sagar is an Ayurvedic wellness content writer with Aarogya Jeevanam and over 6 years of experience writing on digestive health and holistic living.
Disclaimer: This article is for general information only and is not a substitute for medical advice. Please consult a qualified doctor for diagnosis and treatment.
