What is the diagnostic workup for hematospermia?

Diagnostic Workup for Hematospermia

For hematospermia, the diagnostic approach should be stratified by age, with men ≥40 years or those with persistent symptoms requiring more thorough evaluation including PSA testing and imaging, while younger men with isolated episodes often need only basic evaluation. 1

Initial Evaluation

History and Physical Examination

• Key history elements:

  • Duration (single episode vs. persistent/recurrent)
  • Associated symptoms (pain, urinary symptoms, fever)
  • Risk factors (recent procedures, trauma, infections)
  • Sexual history
  • Medication use (anticoagulants)

• Physical examination must include:

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

Basic Laboratory Testing

• Urinalysis and urine culture
• STI testing if clinically indicated
• Complete blood count
• Coagulation profile
• Serum chemistry panel

Risk-Stratified Approach

Low-Risk Patients

• Men <40 years with:
  • Single/transient episode
  • No associated symptoms
  • Normal physical examination

Management:

• Reassurance and watchful waiting
• No imaging typically required 2
• Consider repeat evaluation if symptoms persist

High-Risk Patients

• Men ≥40 years OR
• Any man with:
  • Persistent/recurrent hematospermia
  • Associated symptoms (pain, LUTS, fever)
  • Abnormal physical findings
  • Risk factors (cancer history, anticoagulation)

Management:

• Complete the basic evaluation above
• PSA testing (mandatory in men ≥40) 2, 1
• Imaging studies

Imaging Recommendations

First-Line Imaging

• Transrectal Ultrasound (TRUS)
  • Recommended as initial imaging modality 2, 1
  • Highly sensitive (82-95% detection rate) 2
  • Can identify:
    • Prostatic calcifications/calculi
    • Seminal vesicle abnormalities
    • Ejaculatory duct obstruction
    • Cysts and masses
    • Prostatitis

Second-Line Imaging

• MRI of prostate and seminal tract
  • Indicated when TRUS is negative or inconclusive 2, 1
  • Superior soft tissue contrast
  • Better visualization of seminal vesicles and ejaculatory ducts
  • Can accurately determine organ of origin for prostatic cysts
  • Can identify age and location of hemorrhage 2

Additional Studies (Selected Cases)

• Cystoscopy - for suspected bladder or urethral pathology
• Semen analysis and culture - for suspected infection
• CT scanning - limited value due to poor soft tissue contrast 1

Special Considerations

Pitfalls to Avoid

• Overinvestigation in young patients with single episodes - extensive workup rarely needed 1, 3
• Underinvestigation in older men - PSA and imaging are essential 2, 1
• Missing systemic causes - check blood pressure and coagulation status 4
• Focusing only on prostate - seminal vesicles and ejaculatory ducts are common sources 2

When to Refer to Urology

• Men ≥40 years with hematospermia
• Persistent/recurrent episodes
• Abnormal findings on initial evaluation
• Associated symptoms suggesting underlying pathology
• Elevated PSA

Treatment Approach

Treatment should target the underlying cause when identified:

• Infections - appropriate antimicrobial therapy
• Inflammatory conditions - anti-inflammatory medications
• Structural abnormalities - may require procedural intervention
• Malignancy - refer for appropriate oncologic management

For idiopathic cases (especially in younger men), reassurance is often sufficient as most cases are self-limiting 5, 6.

Remember that hematospermia is rarely associated with significant pathology in younger men, but a structured evaluation is essential to rule out serious conditions, particularly in older men or those with persistent symptoms 4, 6.