How is hematospermia treated?

Treatment of Hematospermia

Most cases of hematospermia are benign and self-limiting, requiring only reassurance for patients under 40 years without risk factors, while persistent cases or those in older men warrant further investigation starting with transrectal ultrasound (TRUS). 1

Age-Based Approach to Evaluation and Treatment

For Men Under 40 Years

• Initial Management:

  • Watchful waiting and reassurance are typically sufficient 1
  • No imaging is generally recommended for transient episodes 1
  • Basic laboratory evaluation:
    • Urinalysis
    • Testing for sexually transmitted infections
    • Semen analysis if indicated

• If Associated with Lower Urinary Tract Symptoms:

  • Treat underlying infection with appropriate antibiotics
  • Most common cause in this age group is urogenital infection 2

For Men 40 Years and Older OR Persistent/Recurrent Cases

• Diagnostic Workup:

  1. Prostate-specific antigen (PSA) testing 1
  2. Transrectal ultrasound (TRUS) as first-line imaging (detects abnormalities in 82-95% of cases) 1
  3. MRI pelvis if TRUS is negative or inconclusive 1

• Common Findings Requiring Treatment:

  • Calcifications/calculi in prostate, ejaculatory ducts, or seminal vesicles
  • Cysts in seminal vesicles, ejaculatory ducts, or prostate
  • Obstruction/stricture at the verumontanum orifice or ejaculatory duct
  • Inflammatory conditions like prostatitis or seminal vesiculitis

Treatment Based on Underlying Cause

1. Infectious Causes (Most Common Identifiable Cause):

   • Appropriate antimicrobial therapy based on culture results
   • Antibiotics for bacterial infections
   • Antivirals for viral infections
   • Antiparasitic agents for parasitic infections 3

2. Obstructive Causes:

   • Transurethral resection of ejaculatory ducts (TURED) for ejaculatory duct obstruction
   • Removal of calculi if present 1

3. Inflammatory Non-infectious Causes:

   • Anti-inflammatory medications
   • Alpha-blockers may help with associated symptoms

4. Vascular Malformations:

   • For intractable cases with identified arterial source:
     • Transcatheter arterial embolization may be performed 1

5. Malignancy:

   • Definitive treatment of the primary lesion (prostate, testis, or seminal vesicle cancers) 3

Important Clinical Considerations

• Hematospermia following prostate biopsy is common and typically resolves within 3-4 weeks 4
• Persistent or recurrent hematospermia with associated symptoms (fever, chills, weight loss, bone pain) requires thorough investigation 2
• Transurethral seminal vesiculoscopy has shown higher diagnostic accuracy (74.5%) than TRUS (45.3%) for persistent cases 1
• Blood pressure assessment is important as hypertension can be an underlying cause 4

Pitfalls to Avoid

1. Missing malignancy in older men by not performing adequate workup
2. Overinvestigation in young men with single episodes and no risk factors
3. Mistaking partner's blood for hematospermia - careful history is essential 1
4. Failure to recognize systemic causes such as bleeding disorders or hypertension
5. Causing unnecessary anxiety by not providing appropriate reassurance when indicated

For most patients, particularly those under 40 without risk factors, hematospermia is a benign condition that resolves spontaneously, and treatment focuses on reassurance and addressing any underlying infections. More extensive evaluation is reserved for older patients, persistent cases, or those with concerning associated symptoms.