What is the workup for hematospermia (blood in semen)?

Workup for Hematospermia (Blood in Semen)

For men with hematospermia, the diagnostic workup should be stratified by age, with men ≥40 years requiring more thorough evaluation including PSA testing, detailed history, physical examination with digital rectal examination, urinalysis, and transrectal ultrasound (TRUS) as the first-line imaging modality. 1

Initial Assessment for All Patients

• Detailed history focusing on:

  • Duration (transient/episodic vs. persistent)
  • Associated symptoms (pain, fever, weight loss, urinary symptoms)
  • Risk factors (recent instrumentation, prostate biopsy, trauma)
  • Sexual history and potential STIs
  • Medication use (anticoagulants)

• Physical examination:

  • Blood pressure measurement (hypertension can be associated)
  • Abdominal examination
  • Genital examination (testicular masses, urethral discharge)
  • Digital rectal examination (prostate abnormalities)

• Basic laboratory testing:

  • Urinalysis
  • Urine culture if infection suspected
  • STI testing if indicated

Age-Based Approach

Men <40 years with single/transient episode and no risk factors:

• Reassurance (likely benign and self-limiting)
• No imaging typically required 2
• Consider treating any identified infections

Men ≥40 years OR any man with persistent/recurrent hematospermia OR concerning symptoms:

1. Laboratory testing:

   • Prostate-specific antigen (PSA) 1, 3
   • Complete blood count
   • Coagulation studies if bleeding disorder suspected

2. Imaging:

   • Transrectal ultrasound (TRUS) as first-line imaging 2, 1
     • Can identify calcifications, cysts, abscesses, ejaculatory duct obstruction, and prostate abnormalities
     • May be both diagnostic and therapeutic in certain cases (e.g., cyst drainage)

3. Advanced imaging when TRUS is inconclusive or negative:

   • MRI of the prostate and seminal tract 2
     • Superior soft tissue contrast
     • Better visualization of seminal vesicles, ejaculatory ducts, and prostate
     • Preferred at 1.5T or 3T (3T offers better signal-to-noise ratio)
     • No endorectal coil needed with 3T MRI

4. Additional procedures based on findings:

   • TRUS-guided aspiration or biopsy of seminal vesicles/prostate if:
     • Prostate cancer is suspected
     • Definitive diagnosis of a lesion is needed
     • Confirmation of ejaculatory duct obstruction is required 2

Special Considerations

• CT scanning has limited value due to poor soft tissue contrast 2

• Pelvic angiography should be reserved for intractable hematospermia when other evaluations have not revealed an etiology 2

• Cystoscopy may be considered in cases with concurrent hematuria or when other evaluations are inconclusive

Common Pitfalls to Avoid

1. Failure to stratify by age: Men ≥40 years require more thorough evaluation due to increased risk of underlying pathology 1, 3

2. Overlooking iatrogenic causes: In men ≥40 years, the most common cause is often iatrogenic from urogenital instrumentation or prostate biopsy 3

3. Missing systemic causes: Conditions like hypertension and bleeding disorders can contribute to hematospermia 3, 4

4. Unnecessary imaging in young patients: For men <40 years with a single episode and no risk factors, extensive imaging is usually not indicated 2, 3

5. Delayed referral: Persistent or recurrent hematospermia, especially with associated symptoms, warrants prompt urological referral

By following this structured approach, clinicians can appropriately evaluate hematospermia while avoiding unnecessary testing in low-risk patients and ensuring thorough evaluation in those at higher risk for significant underlying pathology.