What is the initial evaluation for a 59-year-old (yo) male with hematospermia (blood in semen)?

Initial Evaluation for a 59-Year-Old Male with Hematospermia

For a 59-year-old male with hematospermia, the initial evaluation should include prostate-specific antigen (PSA) testing, detailed history, physical examination with digital rectal examination, urinalysis, and transrectal ultrasound (TRUS) as the first-line imaging modality. 1

Age-Based Approach to Hematospermia

The approach to hematospermia varies significantly based on patient age:

• Age ≥40 years (including our 59-year-old patient): Requires thorough evaluation due to higher risk of underlying pathology
• Age <40 years: Often benign and self-limiting, may only require reassurance if isolated and without risk factors 1, 2

Initial Diagnostic Algorithm for a 59-Year-Old with Hematospermia

Step 1: History and Physical Examination

• History elements to document:

  • Duration and frequency of hematospermia (single episode vs. persistent/recurrent)
  • Associated symptoms (fever, chills, weight loss, bone pain, urinary symptoms)
  • History of urogenital procedures/instrumentation
  • Sexual history and potential STIs
  • Trauma history
  • Medication use (especially anticoagulants)
  • Systemic diseases (hypertension, bleeding disorders)

• Physical examination:

  • Blood pressure measurement (hypertension association)
  • Genital examination for discharge, lesions
  • Digital rectal examination of prostate (essential in this age group)

Step 2: Laboratory Testing

• PSA testing (mandatory in men ≥40 years) 1
• Urinalysis and urine culture
• Testing for sexually transmitted infections if indicated
• Complete blood count if systemic bleeding disorder suspected

Step 3: Imaging

• Transrectal ultrasound (TRUS) as first-line imaging 1

  • Highly rated (8/9) in ACR Appropriateness Criteria
  • Can detect abnormalities in 82-95% of men with hematospermia
  • Can identify calcifications, cysts, hypertrophy, prostatitis, and masses

• If TRUS is negative or inconclusive:

  • MRI pelvis without and with IV contrast (rated 8/9)
  • MRI pelvis without IV contrast (rated 7/9)
  • CT and angiography generally not recommended (rated 1-2/9) 1

Common Causes to Consider in a 59-Year-Old

1. Iatrogenic causes (most common in men ≥40)

   • Recent prostate biopsy or urogenital instrumentation

2. Infectious/inflammatory conditions (39-55% of cases)

   • Prostatitis
   • Seminal vesiculitis
   • Epididymitis

3. Prostatic pathology

   • Benign prostatic hyperplasia
   • Prostatic calculi or cysts
   • Prostate cancer

4. Other causes

   • Vascular malformations
   • Ejaculatory duct obstruction
   • Systemic conditions (hypertension, bleeding disorders)

Pitfalls to Avoid

• Underinvestigation: At age 59, hematospermia should never be dismissed without proper evaluation, as the risk of underlying malignancy increases with age 2, 3

• Overinvestigation: Not every patient needs extensive imaging beyond TRUS unless there are persistent symptoms or concerning findings 1, 4

• Missing systemic causes: Remember to check blood pressure and consider bleeding disorders 5, 6

• Focusing only on the prostate: Consider the entire genitourinary tract as potential sources of bleeding 3

By following this systematic approach, clinicians can effectively evaluate hematospermia in older men while balancing the need for thorough investigation with appropriate resource utilization.