What is the workup for hematospermia?

Workup for Hematospermia

The workup for hematospermia should be stratified by age, with men under 40 years with isolated episodes requiring only basic evaluation, while men 40 years or older and those with persistent symptoms need thorough evaluation including PSA testing and imaging. 1

Initial Assessment

History

• Duration and frequency of episodes
• Associated symptoms (pain, lower urinary tract symptoms)
• Risk factors (recent procedures, trauma)
• Sexual history (new partners, practices)
• Medication use (anticoagulants)

Physical Examination

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

Basic Laboratory Testing

• Urinalysis
• Urine culture if infection is suspected

Age-Based Approach

Men Under 40 Years

• For single/transient episode with normal physical examination:
  • Reassurance and watchful waiting
  • No imaging typically required 1, 2
• For recurrent episodes:
  • Consider urinalysis and urine culture
  • Consider STI screening

Men 40 Years or Older

• More thorough evaluation required:
  • PSA testing
  • Transrectal Ultrasound (TRUS) as initial imaging (82-95% detection rate) 1
  • Evaluation for malignancy

Advanced Diagnostic Workup (for persistent/recurrent cases)

1. Imaging Studies:

   • TRUS: First-line imaging to identify prostatic calcifications, seminal vesicle abnormalities, ejaculatory duct obstruction, cysts, and masses 1
   • MRI: When TRUS is negative or inconclusive; provides superior soft tissue contrast and better visualization of seminal tract 1
   • CT: Limited value due to poor soft tissue contrast 1

2. Specialized Testing:

   • Semen culture for infectious causes
   • Ejaculate analysis
   • Cystoscopy for persistent cases 3

Management Approach

Treatment should target the underlying cause when identified:

• Infections: Appropriate antibiotics (common pathogens include S. aureus, U. urealyticum, E. coli) 4
• Inflammatory conditions: Anti-inflammatory medications
• Structural abnormalities: Surgical intervention if needed
• Hypertension: Blood pressure control
• Idiopathic cases: Reassurance (most cases are self-limiting) 1

Common Pitfalls to Avoid

• Overinvestigation in young patients with single episodes 1
• Underinvestigation in older men (≥40 years) where PSA and imaging are essential 1
• Focusing only on prostate while neglecting seminal vesicles and ejaculatory ducts as common sources 1
• Missing systemic causes such as hypertension and coagulation disorders 1, 5
• Delayed referral for persistent or recurrent hematospermia, especially with associated symptoms 1

When to Refer to Urology

• Men ≥40 years with hematospermia
• Persistent or recurrent episodes
• Abnormal findings on initial evaluation
• Associated symptoms (pain, lower urinary tract symptoms)
• Elevated PSA
• Abnormal imaging findings

Remember that hematospermia is most commonly due to benign causes, particularly in younger men, but a structured evaluation is essential to rule out serious conditions, especially in older men or those with persistent symptoms 1, 5.