Mixed hemorrhoids combine internal and external types, so you get the best (or worst) of both worlds: painless bleeding plus painful lumps.

Bleeding is the first clue. Bright-red blood drips into the bowl or shows on paper, usually without pain.

Protrusion follows. A soft lump slides out with bowel movement and may stay outside or need to be pushed back.

Pain kicks in later. When the internal part swells, it pulls the external skin with it, causing a deep, throbbing ache.

Swelling and itching surround the anus. The area feels puffy, hot, and makes you want to scratch.

Mucus and wetness occur. The internal portion leaks fluid, irritating the skin and staining underwear.

Late signs include a hard, purple lump or continuous bleeding—an alarm that the veins have clotted.